Provider Demographics
NPI:1285206250
Name:MIND HAVEN BEHAVIORAL CLINIC LLC
Entity Type:Organization
Organization Name:MIND HAVEN BEHAVIORAL CLINIC LLC
Other - Org Name:MIND HAVEN BEHAVIORAL CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NONYE
Authorized Official - Middle Name:
Authorized Official - Last Name:NWOKORO
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:682-365-0875
Mailing Address - Street 1:2201 N COLLINS ST STE 180
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-2609
Mailing Address - Country:US
Mailing Address - Phone:682-365-0875
Mailing Address - Fax:
Practice Address - Street 1:120 MADEIRA DR NE STE 219
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1537
Practice Address - Country:US
Practice Address - Phone:683-365-0875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-10
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty