Provider Demographics
NPI:1336957778
Name:MIND MEDICINE LLC
Entity type:Organization
Organization Name:MIND MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:MCCARTY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:563-320-6915
Mailing Address - Street 1:1225 E RIVER DR STE 330
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-5761
Mailing Address - Country:US
Mailing Address - Phone:563-424-0136
Mailing Address - Fax:563-526-4116
Practice Address - Street 1:1225 E RIVER DR STE 340
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-5761
Practice Address - Country:US
Practice Address - Phone:563-424-0136
Practice Address - Fax:563-526-4116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty