Provider Demographics
NPI:1003565979
Name:MIND OVER MATTER HEALTH SERVICES, INC
Entity type:Organization
Organization Name:MIND OVER MATTER HEALTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:410-982-1353
Mailing Address - Street 1:10016 MARRIOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-1502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10016 MARRIOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-1502
Practice Address - Country:US
Practice Address - Phone:443-405-1095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASIA JOHNSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD300269100Medicaid