Provider Demographics
NPI: | 1760061691 |
---|---|
Name: | MINDSHIFT PSYCHIATRY PLLC |
Entity Type: | Organization |
Organization Name: | MINDSHIFT PSYCHIATRY PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ROSCELLE |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | MINOZA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 818-388-2991 |
Mailing Address - Street 1: | 10161 PARK RUN DR STE 150 |
Mailing Address - Street 2: | |
Mailing Address - City: | LAS VEGAS |
Mailing Address - State: | NV |
Mailing Address - Zip Code: | 89145-8872 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 702-748-9726 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1811 S RAINBOW BLVD STE 201 |
Practice Address - Street 2: | |
Practice Address - City: | LAS VEGAS |
Practice Address - State: | NV |
Practice Address - Zip Code: | 89146-0855 |
Practice Address - Country: | US |
Practice Address - Phone: | 702-748-9726 |
Practice Address - Fax: | 702-608-8528 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-04-07 |
Last Update Date: | 2023-03-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Single Specialty |