MEDICARE: HER MIND HER BODY WELLNESS PROGRAM

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	251S00000X	Community/Behavioral Health Agency		MD

General Provider Information

NPI Number	:	1508297292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HER MIND HER BODY WELLNESS PROGRAM

Provider Business Mailing Address
First Line	:	3104 LORD BALTIMORE DR STE 202
Second Line	:
City	:	WINDSOR MILL
State	:	MD
Zip	:	21244-5802
Country	:	US
Telephone Number	:	410-298-4642
Fax Number	:

Provider Business Practice Location Address
First Line	:	3104 LORD BALTIMORE DR STE 202
Second Line	:
City	:	WINDSOR MILL
State	:	MD
Zip	:	21244-5802
Country	:	US
Telephone Number	:	410-298-4642
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	SHANIKA LA'TIA BURKE
Credential	:
Telephone Number	:	443-977-8879

Provider Enumeration Date	:	12/05/2013
Last Update Date	:	03/06/2026

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