Healthcare Provider Details

I. General information

NPI: 1265025050
Provider Name (Legal Business Name): WISEMIND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E THOMAS RD STE 2200
PHOENIX AZ
85012-3133
US

IV. Provider business mailing address

P.O. BOX 33784
PHOENIX AZ
85067-3784
US

V. Phone/Fax

Practice location:
  • Phone: 541-990-2613
  • Fax:
Mailing address:
  • Phone: 480-359-5816
  • Fax: 833-520-1481

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
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. NATHAN DINGELDEIN
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: PMHNP, BC
Phone: 541-990-2613