Provider Demographics
NPI:1235721085
Name:WELLNESS BOUND MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:WELLNESS BOUND MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KIDBY
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:541-295-5172
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-0047
Mailing Address - Country:US
Mailing Address - Phone:971-275-8387
Mailing Address - Fax:866-868-4840
Practice Address - Street 1:18357 ANDY HILL RD
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-9092
Practice Address - Country:US
Practice Address - Phone:541-525-0779
Practice Address - Fax:866-868-4840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-03
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1235721085OtherFACILITY NPI
OR1902441959OtherINDIVIDUAL NPI
OR500704924Medicaid
OR1124427950OtherINDIVIDUAL NPI
OR1902441959Medicaid