Provider Demographics
NPI:1730935610
Name:MENTAL EDGE PSYCHIATRY AND WELLNESS, LLC
Entity type:Organization
Organization Name:MENTAL EDGE PSYCHIATRY AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/CONTRACTING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-984-7174
Mailing Address - Street 1:3208 E COLONIAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5127
Mailing Address - Country:US
Mailing Address - Phone:321-357-4684
Mailing Address - Fax:
Practice Address - Street 1:3208 E COLONIAL DR STE C
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5127
Practice Address - Country:US
Practice Address - Phone:321-357-4684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)