Healthcare Provider Details

I. General information

NPI: 1104738848
Provider Name (Legal Business Name): MINDSCAPE PSYCHIATRIC WELLNESS NURSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 HIGHLAND POINTE DR STE 250
ROSEVILLE CA
95678-5421
US

IV. Provider business mailing address

915 HIGHLAND POINTE DR STE 250
ROSEVILLE CA
95678-5421
US

V. Phone/Fax

Practice location:
  • Phone: 805-766-0268
  • Fax:
Mailing address:
  • Phone: 805-766-0268
  • 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

VIII. Authorized Official

Name: REX AMBATALI
Title or Position: NP
Credential: MSN, PMHNP-BC
Phone: 805-766-0268