Provider Demographics
NPI:1609449677
Name:LIGHT AND MIND WELLNESS LLC
Entity Type:Organization
Organization Name:LIGHT AND MIND WELLNESS LLC
Other - Org Name:LIGHT AND MIND WELLNESS LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:AISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSAN-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CNS,PMH-NP, APRN
Authorized Official - Phone:443-239-2033
Mailing Address - Street 1:8707 COMMERCE DR STE E
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-6910
Mailing Address - Country:US
Mailing Address - Phone:443-239-2033
Mailing Address - Fax:855-461-3481
Practice Address - Street 1:811 N BROAD ST STE 225A
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1173
Practice Address - Country:US
Practice Address - Phone:443-239-2033
Practice Address - Fax:855-461-3481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE250696270Medicaid
MD206453701Medicaid