MEDICARE: RENEW YOUR MIND WELLNESS SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1396441416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEW YOUR MIND WELLNESS SERVICES LLC

Provider Business Mailing Address
First Line	:	9091 SNOWDEN RIVER PKWY # 1316
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21046-1657
Country	:	US
Telephone Number	:	443-690-2272
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 TWIN KNOLLS RD STE 107
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-3260
Country	:	US
Telephone Number	:	443-690-2272
Fax Number	:	855-450-1084

Authorized Official
Title or Position	:	ADMIN/PROVIDER
Name	:	KATIA COLEY
Credential	:
Telephone Number	:	240-350-3015

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	06/29/2024

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