Provider Demographics
NPI:1639690159
Name:NIRVANA MENTAL HEALTHCARE SERVICES INC
Entity type:Organization
Organization Name:NIRVANA MENTAL HEALTHCARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:844-779-2437
Mailing Address - Street 1:PO BOX 8244
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-8244
Mailing Address - Country:US
Mailing Address - Phone:575-624-2095
Mailing Address - Fax:
Practice Address - Street 1:400 N PENNSYLVANIA AVE STE 670D
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4754
Practice Address - Country:US
Practice Address - Phone:844-779-2437
Practice Address - Fax:575-208-0780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-06
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03247363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4482000Medicaid