Basic Information
| Provider Information | |||||||||
| NPI: | 1346759495 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC MIND INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2596 N STOKESBERRY PL STE 165 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836466281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086310843 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2596 N STOKESBERRY PL STE 165 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836466281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086310843 | ||||||||
| FaxNumber: | 2089060807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | VAN LEUVEN | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2086310843 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.