Provider Demographics
NPI:1821812389
Name:STATE OF MIND PSYCHIATRY, LLC
Entity type:Organization
Organization Name:STATE OF MIND PSYCHIATRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:662-268-7100
Mailing Address - Street 1:12183 MS HIGHWAY 182 STE 103C
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-1653
Mailing Address - Country:US
Mailing Address - Phone:662-268-7100
Mailing Address - Fax:
Practice Address - Street 1:12181 MS HIGHWAY 182
Practice Address - Street 2:SUITE 103C
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:256-996-4801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-12
Last Update Date:2024-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty