Provider Demographics
NPI:1326821620
Name:EVOLVING MINDS MENTAL HEALTH
Entity Type:Organization
Organization Name:EVOLVING MINDS MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TILLEMANS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, PMHNP-BC
Authorized Official - Phone:775-247-7624
Mailing Address - Street 1:409 S 8TH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 S 8TH ST STE 207
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7136
Practice Address - Country:US
Practice Address - Phone:208-918-2675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
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
ID1548830573Medicaid