Healthcare Provider Details

I. General information

NPI: 1740070317
Provider Name (Legal Business Name): OPTIMA MENTAL HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 05/08/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 TWELVE OAKS CENTER DR STE 820A
WAYZATA MN
55391-4640
US

IV. Provider business mailing address

801 TWELVE OAKS CENTER DR STE 820A
WAYZATA MN
55391-4640
US

V. Phone/Fax

Practice location:
  • Phone: 320-447-4792
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MERCY SHWEMBOM
Title or Position: OWNER/CLINICIAN
Credential: PMHNP-BC
Phone: 320-447-4792