=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396307401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A PURPOSEFUL MIND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2019
-----------------------------------------------------
Last Update Date | 12/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3925 N MLK BLVD STE 122
-----------------------------------------------------
City | NORTH LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89032-7675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-526-8453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3925 N MLK BLVD STE 122
-----------------------------------------------------
City | NORTH LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89032-7675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-526-8453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YOLANDA STANDIFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 661-526-8453
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------