=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487321089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND OVER MATTER BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2021
-----------------------------------------------------
Last Update Date | 08/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 E COVINGTON AVE
-----------------------------------------------------
City | OPP
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36467-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-804-6937
-----------------------------------------------------
Fax | 716-265-3348
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 E COVINGTON AVE
-----------------------------------------------------
City | OPP
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36467-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-804-6937
-----------------------------------------------------
Fax | 716-265-3348
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DAVID RUSSELL ADAMS
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 334-804-6937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------