=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902687932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAL MINDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2023
-----------------------------------------------------
Last Update Date | 10/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9122 MONTGOMERY RD STE 18
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-7746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-268-8575
-----------------------------------------------------
Fax | 512-268-2052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9292 STEEPLECHASE DR
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-268-8575
-----------------------------------------------------
Fax | 513-268-2052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | DR. KELLY ANN ICKES
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 513-268-8575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------