Healthcare Provider Details

I. General information

NPI: 1730861964
Provider Name (Legal Business Name): MENTEM PSYCHIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E 5TH ST STE 202
WATERLOO IA
50703-4757
US

IV. Provider business mailing address

315 E 5TH ST STE 202
WATERLOO IA
50703-4757
US

V. Phone/Fax

Practice location:
  • Phone: 515-681-5415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELSEY ANDRESEN
Title or Position: ARNP
Credential: ARNP
Phone: 515-681-5415