Provider Demographics
NPI:1396479697
Name:TOTALLY PSYCHED, LLC
Entity type:Organization
Organization Name:TOTALLY PSYCHED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:OLDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:817-689-3369
Mailing Address - Street 1:15161 NEWTONIA ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5647
Mailing Address - Country:US
Mailing Address - Phone:817-689-3369
Mailing Address - Fax:
Practice Address - Street 1:1223 DANIELS RD
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3835
Practice Address - Country:US
Practice Address - Phone:689-240-7945
Practice Address - Fax:833-973-2664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-12
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health