Provider Demographics
NPI:1801675491
Name:MINDBRANCH MENTAL HEALTH SERVICES
Entity type:Organization
Organization Name:MINDBRANCH MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:FOX
Authorized Official - Suffix:JR
Authorized Official - Credentials:APRN
Authorized Official - Phone:812-946-2674
Mailing Address - Street 1:1400 MAIN ST UNIT 177
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-3108
Mailing Address - Country:US
Mailing Address - Phone:812-946-2674
Mailing Address - Fax:
Practice Address - Street 1:1400 MAIN ST UNIT 177
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-3108
Practice Address - Country:US
Practice Address - Phone:812-946-2674
Practice Address - Fax:844-832-9625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty