Basic Information
| Provider Information | |||||||||
| NPI: | 1427351873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIND SPA, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIND SPA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 719 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075090772 | ||||||||
| FaxNumber: | 3074264133 | ||||||||
| Practice Location | |||||||||
| Address1: | 719 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075090772 | ||||||||
| FaxNumber: | 3074264133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2010 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLUELLEN | ||||||||
| AuthorizedOfficialFirstName: | SHERI | ||||||||
| AuthorizedOfficialMiddleName: | JOLENE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3075090772 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3495 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 498 | WY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 3495 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | 498 | WY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC1900X | 3495 | CO | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 261QM0855X | WY498 | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | WY498 | WY | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0801X | 498 | WY | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 103T00000X | 498 | WY | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.