Basic Information
| Provider Information | |||||||||
| NPI: | 1811331051 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIND SPA PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIND SPA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 719 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075090772 | ||||||||
| FaxNumber: | 3074264133 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 N LAST CHANCE GULCH | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | HELENA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 596015012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075090772 | ||||||||
| FaxNumber: | 3074264133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2013 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLUELLEN | ||||||||
| AuthorizedOfficialFirstName: | SHERI | ||||||||
| AuthorizedOfficialMiddleName: | JOLENE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3075090772 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 498 | WY | Y | Agencies | Community/Behavioral Health |
No ID Information.