MEDICARE: CHANGE OF MIND LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1053264788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGE OF MIND LLC

Provider Business Mailing Address
First Line	:	11331 E STARFIRE CIR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85212-7062
Country	:	US
Telephone Number	:	148-068-6017
Fax Number	:

Provider Business Practice Location Address
First Line	:	11331 E STARFIRE CIR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85212-7062
Country	:	US
Telephone Number	:	148-068-6017
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MS. SUSAN ANN WILLEVER
Credential	:	PMHNP
Telephone Number	:	480-686-0170

Provider Enumeration Date	:	02/20/2026
Last Update Date	:	02/20/2026

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Directions to “CHANGE OF MIND LLC ” Practice Location

Language	Start Address	Practice Location

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