Provider Demographics
NPI:1073121935
Name:VITAL MENTAL HEALTH SPECIALISTS LLC
Entity Type:Organization
Organization Name:VITAL MENTAL HEALTH SPECIALISTS LLC
Other - Org Name:VITAL MENTAL HEALTH SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THEOPHILUS
Authorized Official - Middle Name:MBI
Authorized Official - Last Name:AKOH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:775-335-7450
Mailing Address - Street 1:1821 UNIVERSITY AVE W STE 298
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2875
Mailing Address - Country:US
Mailing Address - Phone:651-756-8183
Mailing Address - Fax:651-756-8336
Practice Address - Street 1:1821 UNIVERSITY AVE W STE 298
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2875
Practice Address - Country:US
Practice Address - Phone:651-756-8183
Practice Address - Fax:651-756-8336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)