=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629737473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENLIGHTENMENT PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2021
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 1ST ST E STE 5
-----------------------------------------------------
City | PARK RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56470-1764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-321-9599
-----------------------------------------------------
Fax | 877-962-3624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 1ST ST E STE 5
-----------------------------------------------------
City | PARK RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56470-1764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-321-9599
-----------------------------------------------------
Fax | 877-962-3624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP/FOUNDER
-----------------------------------------------------
Name | MACKENZIE SNORTUM
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 320-321-9599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------