=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881242998
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUND MIND MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2019
-----------------------------------------------------
Last Update Date | 09/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19751 E MAINSTREET STE 235
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80138-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-257-9049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19751 E MAINSTREET STE 235
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80138-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-257-9049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CANDACE HOUSTON DEYERLING
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 720-257-9049
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------