Healthcare Provider Details

I. General information

NPI: 1053087445
Provider Name (Legal Business Name): ELEVATING MINDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1632 KITTYHAWK DR
LITTLE ELM TN
75068
US

IV. Provider business mailing address

1632 KITTYHAWK DR
LITTLE ELM TN
75068
US

V. Phone/Fax

Practice location:
  • Phone: 702-490-2786
  • 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

VIII. Authorized Official

Name: CHARMAINE WILCOX
Title or Position: OWNER
Credential:
Phone: 702-490-2786