1568293728 NPI number — MIND MAP WELLNESS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568293728 NPI number — MIND MAP WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND MAP WELLNESS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568293728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3030 GREENMOUNTE AVE
Provider Second Line Business Mailing Address:
STE 300 PMB 183594
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-929-1499
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
53 WANOMA CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REHOBOTH BEACH
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19971-7704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-929-1499
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2024

Additional Information

Authorized Official

Authorized Official Last Name:
BOLLAND
Authorized Official First Name:
IAN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
SOLE MEMBER/OWNER
Authorized Official Telephone Number:
410-929-1499

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LC9569 . This is a "LICENSED CLINICAL PROFESSIONAL COUNSELOR" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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