MEDICARE: MIND SPA 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	1041C0700X	Clinical Social Worker	2641	OK
2	164W00000X	Licensed Practical Nurse	63489	OK
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
4	2084P0800X	Psychiatry Physician	4200	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891932216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND SPA LLC

Provider Business Mailing Address
First Line	:	7302 S YALE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-7027
Country	:	US
Telephone Number	:	918-591-2510
Fax Number	:	918-591-2511

Provider Business Practice Location Address
First Line	:	7302 S YALE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-7027
Country	:	US
Telephone Number	:	918-591-2510
Fax Number	:	918-591-2511

Authorized Official
Title or Position	:	OWNER/MIND SPA LLC
Name	:	DR. SARAH E LAND
Credential	:	D.O.
Telephone Number	:	918-591-2510

Provider Enumeration Date	:	01/08/2009
Last Update Date	:	09/30/2022

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Directions to “MIND SPA LLC ” Practice Location

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