Provider Demographics
NPI:1811358492
Name:MENTAL WELLNESS INC
Entity type:Organization
Organization Name:MENTAL WELLNESS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:JO COOMER
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:CNS, APRN-BC
Authorized Official - Phone:507-779-4795
Mailing Address - Street 1:192 N AVON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9513
Mailing Address - Country:US
Mailing Address - Phone:317-672-6400
Mailing Address - Fax:317-672-6401
Practice Address - Street 1:192 N AVON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9513
Practice Address - Country:US
Practice Address - Phone:317-672-6400
Practice Address - Fax:317-672-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000195A364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730265356OtherPROVIDER NPI
IN200285820Medicaid