Basic Information
| Provider Information | |||||||||
| NPI: | 1881148559 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIND MATTERS RESOURCE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4022 DUDLEY AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212132139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432086156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 204 W SARATOGA ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212013511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432086156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2016 | ||||||||
| LastUpdateDate: | 08/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROLES | ||||||||
| AuthorizedOfficialFirstName: | LATASHA | ||||||||
| AuthorizedOfficialMiddleName: | GENELL | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4432086156 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.