=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366253817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNATE WISDOM PSYCHIATRY & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2025
-----------------------------------------------------
Last Update Date | 05/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8795 RALSTON RD STE 114D
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80002-2378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-263-6074
-----------------------------------------------------
Fax | 720-647-4170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1488
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80001-1488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-263-6074
-----------------------------------------------------
Fax | 720-647-4170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL PLASTINO
-----------------------------------------------------
Credential | APN, PMHNP-BC
-----------------------------------------------------
Telephone | 720-263-6074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------