Healthcare Provider Details

I. General information

NPI: 1427351873
Provider Name (Legal Business Name): MIND SPA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 E 17TH ST
CHEYENNE WY
82001-4711
US

IV. Provider business mailing address

719 E 17TH ST
CHEYENNE WY
82001-4711
US

V. Phone/Fax

Practice location:
  • Phone: 307-509-0772
  • Fax: 307-426-4133
Mailing address:
  • Phone: 307-509-0772
  • Fax: 307-426-4133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3495
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number498
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3495
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number498
License Number StateWY
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3495
License Number StateCO
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberWY498
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberWY498
License Number StateWY
# 8
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number498
License Number StateWY
# 9
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number498
License Number StateWY

VIII. Authorized Official

Name: DR. SHERI JOLENE FLUELLEN
Title or Position: CEO
Credential: PH.D.
Phone: 307-509-0772