MEDICARE: IMPACT MINDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251G00000X	Community Based Hospice Care Agency
2	283Q00000X	Psychiatric Hospital
3	3104A0625X	Assisted Living Facility (Mental Illness)
4	311Z00000X	Custodial Care Facility
5	3104A0630X	Assisted Living Facility (Behavioral Disturbances)
6	310500000X	Mental Illness Intermediate Care Facility
7	311ZA0620X	Adult Care Home Facility
8	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
9	320700000X	Physical Disabilities Residential Treatment Facility
10	320800000X	Mental Illness Community Based Residential Treatment Facility
11	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
12	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility
13	324500000X	Substance Abuse Rehabilitation Facility
14	3245S0500X	Children's Substance Abuse Rehabilitation Facility
15	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1740969567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT MINDS

Provider Business Mailing Address
First Line	:	9535 FOREST LN STE 119
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-6120
Country	:	US
Telephone Number	:	469-518-3081
Fax Number	:

Provider Business Practice Location Address
First Line	:	9535 FOREST LN STE 119
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-6120
Country	:	US
Telephone Number	:	469-518-3081
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. ASHANTI MENDHEIM
Credential	:
Telephone Number	:	469-518-3081

Provider Enumeration Date	:	07/18/2023
Last Update Date	:	07/18/2023

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Directions to “IMPACT MINDS ” Practice Location

Language	Start Address	Practice Location

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