Provider Demographics
NPI:1225606452
Name:THRIVE PSYCHIATRIC SERVICES PLLC
Entity Type:Organization
Organization Name:THRIVE PSYCHIATRIC SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC, CNP
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CNP, PMHNP-BC
Authorized Official - Phone:605-271-6582
Mailing Address - Street 1:3701 W 49TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-4219
Mailing Address - Country:US
Mailing Address - Phone:605-271-6582
Mailing Address - Fax:
Practice Address - Street 1:3701 W 49TH ST STE 206
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-4219
Practice Address - Country:US
Practice Address - Phone:605-271-6582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty