Provider Demographics
NPI:1689191223
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-982-1353
Mailing Address - Street 1:2001 FITZWARREN PL APT T1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4956
Mailing Address - Country:US
Mailing Address - Phone:410-982-1353
Mailing Address - Fax:
Practice Address - Street 1:616 OLD EDMONDSON AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-3312
Practice Address - Country:US
Practice Address - Phone:443-405-1095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health