Provider Demographics
NPI:1417437542
Name:MIND OVER MATTER MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:MIND OVER MATTER MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:DIRICCO
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, RN
Authorized Official - Phone:509-934-1925
Mailing Address - Street 1:1717 W FRANCIS AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6858
Mailing Address - Country:US
Mailing Address - Phone:509-934-1925
Mailing Address - Fax:509-868-0874
Practice Address - Street 1:1717 W FRANCIS AVE STE 204
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6858
Practice Address - Country:US
Practice Address - Phone:509-934-1925
Practice Address - Fax:509-868-0874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health