Healthcare Provider Details

I. General information

NPI: 1790621282
Provider Name (Legal Business Name): GOOD STATE OF MIND AND MEDICAL CANNABIS PSYCHIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19427 136TH AVE N
ROGERS MN
55374-4834
US

IV. Provider business mailing address

19427 136TH AVE N
ROGERS MN
55374-4834
US

V. Phone/Fax

Practice location:
  • Phone: 763-516-4476
  • Fax:
Mailing address:
  • Phone: 763-516-4476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HERBERT MATANGA
Title or Position: OWNER- PMHNP-BC
Credential:
Phone: 763-516-4476