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General NPI Number Information
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NPI Number | 1811799398
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Entity Type | Organization
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Legal Business Name | MINDFUL MOOD PSYCHIATRY, PLLC
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Dates
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Enumeration Date | 03/26/2025
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Last Update Date | 03/31/2025
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Provider Practice Location Address
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Address Line | 534 TREJO STREET SUITE 100
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City | REXBURG
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State | ID
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Zip | 83440
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Country | US
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Telephone | 208-206-7066
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Fax |
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Provider Business Mailing Address
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Address Line | 1846 1ST ST # 1031
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City | IDAHO FALLS
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State | ID
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Zip | 83401-4415
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PMHNP
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Name | MICHELLE ANDRUS
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Credential | PMHNP
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Telephone | 208-557-9572
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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