MEDICARE: VIBRANT MENTAL WELLNESS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse

General Provider Information

NPI Number	:	1861257776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIBRANT MENTAL WELLNESS LLC

Provider Business Mailing Address
First Line	:	702 HOUSTON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-5004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	702 HOUSTON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-5004
Country	:	US
Telephone Number	:	763-568-6378
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JACKLINE AUKA
Credential	:
Telephone Number	:	432-267-8216

Provider Enumeration Date	:	02/20/2024
Last Update Date	:	02/20/2024

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Directions to “VIBRANT MENTAL WELLNESS LLC ” Practice Location

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