=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720696586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUND MIND PSYCHOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2020
-----------------------------------------------------
Last Update Date | 10/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 MAIN ST STE 1201B
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-229-2747
-----------------------------------------------------
Fax | 207-517-5078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 MAIN ST STE 1201B
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-229-2747
-----------------------------------------------------
Fax | 207-517-5078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISTOPHER JOHNSON
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 207-229-2747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------