Provider Demographics
NPI: | 1326812611 |
---|---|
Name: | MIND MATTERS THERAPEUTICS |
Entity Type: | Organization |
Organization Name: | MIND MATTERS THERAPEUTICS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT AND CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DESPINA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | O'DOHERTY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | APRN, PMHNP-BC, AGNP |
Authorized Official - Phone: | 860-833-3173 |
Mailing Address - Street 1: | 41 TRIANGLE CIR |
Mailing Address - Street 2: | |
Mailing Address - City: | SANDWICH |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02563-2497 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 860-833-3173 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1500 DISTRICT AVE |
Practice Address - Street 2: | STE 1907 |
Practice Address - City: | BURLINGTON |
Practice Address - State: | MA |
Practice Address - Zip Code: | 01803 |
Practice Address - Country: | US |
Practice Address - Phone: | 860-833-3173 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-11-08 |
Last Update Date: | 2023-11-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Single Specialty |