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General NPI Number Information
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NPI Number | 1487318671
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Entity Type | Organization
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Legal Business Name | 1DERFULL MINDS, INC.
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Dates
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Enumeration Date | 10/25/2021
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Last Update Date | 09/29/2023
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Provider Practice Location Address
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Address Line | 631 CRESENT DR
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City | DESOTO
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State | TX
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Zip | 75115-8017
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Country | US
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Telephone | 469-235-2390
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Fax | 972-637-7576
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Provider Business Mailing Address
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Address Line | 631 CRESENT DR
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City | DESOTO
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State | TX
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Zip | 75115-8017
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Country | US
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Telephone | 469-235-2390
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Fax | 972-637-7576
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Authorized Official
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Title or Position | PRESIDENT/PROGRAM MANAGER
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Name | ELLA MARIE MILES
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Credential | BBA, LVN
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Telephone | 469-235-2390
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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 |
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License Number State |
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