Provider Demographics
NPI:1407505035
Name:HEALTHY MINDS FOR HEALTHY LIVES-PEDIATRIC MENTAL HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:HEALTHY MINDS FOR HEALTHY LIVES-PEDIATRIC MENTAL HEALTH AND WELLNESS
Other - Org Name:HEALTHY MINDS FOR HEALTHY LIVES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MERRILL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CPNP-PC
Authorized Official - Phone:940-217-6720
Mailing Address - Street 1:2207 BROOK AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-6139
Mailing Address - Country:US
Mailing Address - Phone:940-217-6720
Mailing Address - Fax:
Practice Address - Street 1:2207 BROOK AVE STE A
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-6139
Practice Address - Country:US
Practice Address - Phone:940-217-6720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-21
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1633747917Medicaid