{
"Npi": {
"NPI": "1407267305",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "WISE MIND PRACTICE LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6710 MASON ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "OMAHA",
"MailingAddressStateName": "NE",
"MailingAddressPostalCode": "68106-1138",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "402-213-7379",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "427 E KANESVILLE BLVD",
"SecondLinePracticeLocationAddress": "SUITE 305",
"PracticeLocationAddressCityName": "COUNCIL BLUFFS",
"PracticeLocationAddressStateName": "IA",
"PracticeLocationAddressPostalCode": "51503-9079",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "402-999-0813",
"PracticeLocationAddressFaxNumber": "712-248-8813",
"EnumerationDate": "05/13/2014",
"LastUpdateDate": "05/13/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KUPSINEL",
"AuthorizedOfficialFirstName": "MORGAN",
"AuthorizedOfficialMiddleName": "M",
"AuthorizedOfficialTitle": "DIRECTOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LISW IADC IADC",
"AuthorizedOfficialTelephoneNumber": "402-213-7379",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "251S00000X",
"TaxonomyName": "Community/Behavioral Health Agency",
"LicenseNumber": "06785",
"LicenseNumberStateCode": "IA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}