Provider Demographics
NPI:1508428541
Name:BODY MIND & SOUL FAMILY SERVICES, LLC
Entity Type:Organization
Organization Name:BODY MIND & SOUL FAMILY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOBBI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:443-410-8642
Mailing Address - Street 1:1401 MADISON PARK DR STE 201
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5881
Mailing Address - Country:US
Mailing Address - Phone:240-620-6883
Mailing Address - Fax:
Practice Address - Street 1:1401 MADISON PARK DR STE 201
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5881
Practice Address - Country:US
Practice Address - Phone:240-620-6883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-30
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD110595700Medicaid