Provider Demographics
NPI:1235914300
Name:IMMACULATE MINDS LLC
Entity Type:Organization
Organization Name:IMMACULATE MINDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:IMMACULATE
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEYO
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:281-683-6517
Mailing Address - Street 1:10412 CHINA SPRING RD STE F
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-5685
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9554 BROOKHOLLOW DR
Practice Address - Street 2:
Practice Address - City:WOODWAY
Practice Address - State:TX
Practice Address - Zip Code:76712-3207
Practice Address - Country:US
Practice Address - Phone:281-683-6517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty