Provider Demographics
NPI:1447682745
Name:MIND OVER MATTER HEALTH SERVICES
Entity type:Organization
Organization Name:MIND OVER MATTER HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC
Authorized Official - Phone:410-982-1353
Mailing Address - Street 1:2001 FITWARREN PL.
Mailing Address - Street 2:T1
Mailing Address - City:BALTO.
Mailing Address - State:MD
Mailing Address - Zip Code:21209
Mailing Address - Country:US
Mailing Address - Phone:410-982-1353
Mailing Address - Fax:443-766-1713
Practice Address - Street 1:7700 OLD BRANCH AVE
Practice Address - Street 2:#B204
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735
Practice Address - Country:US
Practice Address - Phone:301-868-0849
Practice Address - Fax:301-868-2032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2133251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401138400Medicaid