Healthcare Provider Details

I. General information

NPI: 1861257776
Provider Name (Legal Business Name): VIBRANT MENTAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 HOUSTON ST
FORT WORTH TX
76102-5004
US

IV. Provider business mailing address

702 HOUSTON ST
FORT WORTH TX
76102-5004
US

V. Phone/Fax

Practice location:
  • Phone: 763-568-6378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JACKLINE AUKA
Title or Position: OWNER
Credential:
Phone: 432-267-8216