Healthcare Provider Details

I. General information

NPI: 1235992025
Provider Name (Legal Business Name): OPEN MINDS HEALING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/05/2024
Certification Date: 02/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 E BASELINE RD STE 109
MESA AZ
85206-4629
US

IV. Provider business mailing address

1750 W ROOSEVELT AVE
COOLIDGE AZ
85128-9266
US

V. Phone/Fax

Practice location:
  • Phone: 480-863-6346
  • Fax: 480-716-4081
Mailing address:
  • Phone: 480-772-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: NICOLE L LORE
Title or Position: OWNER
Credential: LCSW
Phone: 480-772-6016