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General NPI Number Information
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NPI Number | 1366167082
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Entity Type | Organization
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Legal Business Name | STATE OF MIND PSYCHIATRY, LLC
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Dates
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Enumeration Date | 10/05/2022
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Last Update Date | 10/05/2022
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Provider Practice Location Address
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Address Line | 4364 WESTERN CENTER BLVD # 2221
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City | FORT WORTH
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State | TX
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Zip | 76137-2043
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Country | US
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Telephone | 817-393-2061
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Fax |
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Provider Business Mailing Address
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Address Line | 4364 WESTERN CENTER BLVD # 2221
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City | FORT WORTH
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State | TX
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Zip | 76137-2043
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Country | US
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Telephone | 817-393-2061
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Fax |
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Authorized Official
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Title or Position | PMHNP
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Name | DR. AMANDA KENNEDY
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Credential | DNP
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Telephone | 817-393-2061
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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