Basic Information
Provider Information | |||||||||
NPI: | 1639821572 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ECCENTRIC MINDS HEALTH & WELLNESS PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4410 CLAIBORNE SQ E STE 334 | ||||||||
Address2: |   | ||||||||
City: | HAMPTON | ||||||||
State: | VA | ||||||||
PostalCode: | 236662074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014505770 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4410 CLAIBORNE SQ E STE 334 | ||||||||
Address2: |   | ||||||||
City: | HAMPTON | ||||||||
State: | VA | ||||||||
PostalCode: | 236662074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014505770 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/21/2022 | ||||||||
LastUpdateDate: | 01/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HORTON | ||||||||
AuthorizedOfficialFirstName: | NADIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
AuthorizedOfficialTelephone: | 4014505770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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AuthorizedOfficialCredential: | FNP-BC, PMHNP-BC | ||||||||
NPICertificationDate: | 01/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.