Provider Demographics
NPI:1205525334
Name:REVERED-HOLISTIC HEALTHCARE LLC
Entity type:Organization
Organization Name:REVERED-HOLISTIC HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADETUTU
Authorized Official - Middle Name:
Authorized Official - Last Name:AWODIPE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:443-621-2203
Mailing Address - Street 1:4518 RUNNYMEADE RD
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6156
Mailing Address - Country:US
Mailing Address - Phone:410-399-4240
Mailing Address - Fax:443-381-0216
Practice Address - Street 1:1045 TAYLOR AVE STE 44A
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-8328
Practice Address - Country:US
Practice Address - Phone:410-399-4240
Practice Address - Fax:443-381-0216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty