Healthcare Provider Details

I. General information

NPI: 1023627734
Provider Name (Legal Business Name): CHANGING MINDS PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 W HORIZON RIDGE PKWY
HENDERSON NV
89052-4666
US

IV. Provider business mailing address

PO BOX 752003
LAS VEGAS NV
89136-2003
US

V. Phone/Fax

Practice location:
  • Phone: 702-405-8088
  • Fax:
Mailing address:
  • Phone: 702-405-8088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAMIE BROWN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 702-405-8088