Healthcare Provider Details

I. General information

NPI: 1811799398
Provider Name (Legal Business Name): MINDFUL MOOD PSYCHIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 TREJO STREET SUITE 100
REXBURG ID
83440
US

IV. Provider business mailing address

1846 1ST ST # 1031
IDAHO FALLS ID
83401-4415
US

V. Phone/Fax

Practice location:
  • Phone: 208-206-7066
  • 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: MICHELLE ANDRUS
Title or Position: PMHNP
Credential: PMHNP
Phone: 208-557-9572