Healthcare Provider Details

I. General information

NPI: 1003179953
Provider Name (Legal Business Name): THUNDERMIST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108A SILVERNAIL RD SUITE 116
PEWAUKEE WI
53072-5526
US

IV. Provider business mailing address

2108A SILVERNAIL RD SUITE 116
PEWAUKEE WI
53072-5526
US

V. Phone/Fax

Practice location:
  • Phone: 888-468-9981
  • Fax:
Mailing address:
  • Phone: 888-468-9981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SEAN B JONES
Title or Position: CEO/PRESIDENT
Credential: LLC
Phone: 888-898-4591