Provider Demographics
NPI:1427351873
Name:MIND SPA, PC
Entity type:Organization
Organization Name:MIND SPA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:JOLENE
Authorized Official - Last Name:FLUELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-509-0772
Mailing Address - Street 1:719 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4711
Mailing Address - Country:US
Mailing Address - Phone:307-509-0772
Mailing Address - Fax:307-426-4133
Practice Address - Street 1:719 E 17TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4711
Practice Address - Country:US
Practice Address - Phone:307-509-0772
Practice Address - Fax:307-426-4133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY498103T00000X, 103TC0700X, 103TC1900X, 261QM0801X
CO3495103T00000X, 103TC0700X, 103TC1900X
WYWY498261QM0850X
WY498261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty