MEDICARE: WELLNESS BOUND MENTAL HEALTH 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1124427950	OTHER	OR	INDIVIDUAL NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1902441959	OTHER	OR	INDIVIDUAL NPI
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	1235721085	OTHER	OR	FACILITY NPI
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235721085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS BOUND MENTAL HEALTH LLC

Provider Business Mailing Address
First Line	:	PO BOX 159
Second Line	:
City	:	WARRENTON
State	:	OR
Zip	:	97146-0159
Country	:	US
Telephone Number	:	971-368-1980
Fax Number	:	541-550-2908

Provider Business Practice Location Address
First Line	:	12999 S MACDONALDS PL
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-7529
Country	:	US
Telephone Number	:	541-295-5172
Fax Number	:	971-362-4818

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	MELISSA JEAN KIDBY
Credential	:	PMHNP-BC
Telephone Number	:	541-295-5172

Provider Enumeration Date	:	02/03/2021
Last Update Date	:	04/10/2026

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