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General NPI Number Information
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NPI Number | 1407267305
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Entity Type | Organization
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Legal Business Name | WISE MIND PRACTICE LLC
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Dates
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Enumeration Date | 05/13/2014
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Last Update Date | 05/13/2014
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Provider Practice Location Address
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Address Line | 427 E KANESVILLE BLVD SUITE 305
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51503-9079
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Country | US
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Telephone | 402-999-0813
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Fax | 712-248-8813
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Provider Business Mailing Address
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Address Line | 6710 MASON ST
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City | OMAHA
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State | NE
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Zip | 68106-1138
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Country | US
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Telephone | 402-213-7379
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MORGAN M KUPSINEL
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Credential | LISW IADC IADC
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Telephone | 402-213-7379
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 06785
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License Number State | IA
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