Provider Demographics
NPI:1497268163
Name:EXCEPTIONAL MINDS
Entity Type:Organization
Organization Name:EXCEPTIONAL MINDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-592-0503
Mailing Address - Street 1:8325 JEEVES CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-4947
Mailing Address - Country:US
Mailing Address - Phone:602-592-0503
Mailing Address - Fax:
Practice Address - Street 1:8325 JEEVES CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4947
Practice Address - Country:US
Practice Address - Phone:602-592-0503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20171737643251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health