{
"Npi": {
"NPI": "1093661241",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PROUD MENTAL HEALTH LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1309 COFFEEN AVE # 19118",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SHERIDAN",
"MailingAddressStateName": "WY",
"MailingAddressPostalCode": "82801-5777",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1309 COFFEEN AVE # 19118",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SHERIDAN",
"PracticeLocationAddressStateName": "WY",
"PracticeLocationAddressPostalCode": "82801-5777",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "657-229-5479",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/09/2026",
"LastUpdateDate": "03/09/2026",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SHAW",
"AuthorizedOfficialFirstName": "JONATHAN",
"AuthorizedOfficialMiddleName": "WAYNE",
"AuthorizedOfficialTitle": "OWNER/CEO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PMHNP",
"AuthorizedOfficialTelephoneNumber": "657-229-5479",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "103T00000X",
"TaxonomyName": "Psychologist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LP0808X",
"TaxonomyName": "Psychiatric/Mental Health Nurse Practitioner",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}