=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417617812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAJEAN'S MENTAL HEALTH BOUTIQUE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2021
-----------------------------------------------------
Last Update Date | 05/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3094 W MARKET ST STE 190
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 133-090-7155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 575 WOODVIEW DR
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44319-1343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-907-1556
-----------------------------------------------------
Fax | 845-859-8649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DEWAN SMITH-MURRAY
-----------------------------------------------------
Credential | APRN CNP
-----------------------------------------------------
Telephone | 330-595-9929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------