Provider Demographics
NPI:1336872381
Name:MENTAL HEALTH AND WELLNESS ON MAIN
Entity Type:Organization
Organization Name:MENTAL HEALTH AND WELLNESS ON MAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESCRIBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:COLLETTE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, APRN
Authorized Official - Phone:913-787-5292
Mailing Address - Street 1:275 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH SPRING
Mailing Address - State:AR
Mailing Address - Zip Code:72554-7484
Mailing Address - Country:US
Mailing Address - Phone:870-907-1060
Mailing Address - Fax:870-907-0707
Practice Address - Street 1:275 MAIN ST
Practice Address - Street 2:
Practice Address - City:MAMMOTH SPRING
Practice Address - State:AR
Practice Address - Zip Code:72554-7484
Practice Address - Country:US
Practice Address - Phone:913-787-5292
Practice Address - Fax:870-606-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-07
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty