Healthcare Provider Details

I. General information

NPI: 1821806605
Provider Name (Legal Business Name): CHANGE MINDSET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 DELL RANGE BLVD SUITE 245 BOX# 3317
CHEYENNE WY
82009
US

IV. Provider business mailing address

2232 DELL RANGE BLVD SUITE 245 BOX# 3317
CHEYENNE WY
82009
US

V. Phone/Fax

Practice location:
  • Phone: 973-517-0182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAUNTRA LAMOTTE- OSBORNE
Title or Position: OWNER / BCHHP
Credential: BCHHP, CHN
Phone: 973-517-0182