Provider Demographics
NPI:1285247486
Name:MASTERMIND CLINIC PLLC
Entity type:Organization
Organization Name:MASTERMIND CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STORMES
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, RXN, PMHN
Authorized Official - Phone:209-327-3366
Mailing Address - Street 1:320 E FONTANERO ST STE 301
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7526
Mailing Address - Country:US
Mailing Address - Phone:719-644-6463
Mailing Address - Fax:844-579-0123
Practice Address - Street 1:320 E FONTANERO ST STE 301
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7526
Practice Address - Country:US
Practice Address - Phone:719-644-6463
Practice Address - Fax:844-579-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty