Healthcare Provider Details

I. General information

NPI: 1073366431
Provider Name (Legal Business Name): SPROUTING MINDS ART THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1B BACKROAD
MADRID NM
87010-9727
US

IV. Provider business mailing address

1 BACKROAD
MADRID NM
87010-9727
US

V. Phone/Fax

Practice location:
  • Phone: 515-996-0278
  • Fax:
Mailing address:
  • Phone: 515-996-0278
  • 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: MANDY KAY SPROUL
Title or Position: OWNER/ ART THERAPIST
Credential: LPCC, LPAT
Phone: 515-996-0278