Provider Demographics
NPI:1407547441
Name:MAIN STREET MENTAL HEALTH PLLC
Entity Type:Organization
Organization Name:MAIN STREET MENTAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:641-442-6615
Mailing Address - Street 1:307 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:50103-1025
Mailing Address - Country:US
Mailing Address - Phone:641-442-6615
Mailing Address - Fax:
Practice Address - Street 1:307 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:IA
Practice Address - Zip Code:50103-1025
Practice Address - Country:US
Practice Address - Phone:641-442-6615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty