=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376012377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORIGINAL MIND PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2018
-----------------------------------------------------
Last Update Date | 11/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 W MAIN ST
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05477-4451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-688-3466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1079
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05477-1079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-688-3466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LOGAN HEGG
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 347-688-3466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------