Provider Demographics
NPI:1932627239
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC,LCAD-AS,MAC,AOS
Authorized Official - Phone:443-405-1095
Mailing Address - Street 1:616 OLD EDMONDSON AVE. STE. 4
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228
Mailing Address - Country:US
Mailing Address - Phone:443-405-1095
Mailing Address - Fax:
Practice Address - Street 1:616 OLD EDMONDSON AVE. STE. 4
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228
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:2017-09-07
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD2133251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty