=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255984779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TANGLED MINDS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2019
-----------------------------------------------------
Last Update Date | 08/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 475 PALMER AVE
-----------------------------------------------------
City | BENNETT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80102-7837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-383-7095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23
-----------------------------------------------------
City | BENNETT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80102-0023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-383-7095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAMELA COLLINS
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 720-383-7095
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------