Provider Demographics
NPI:1487318671
Name:1DERFULL MINDS, INC.
Entity type:Organization
Organization Name:1DERFULL MINDS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:BBA, LVN
Authorized Official - Phone:469-235-2390
Mailing Address - Street 1:631 CRESENT DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8017
Mailing Address - Country:US
Mailing Address - Phone:469-235-2390
Mailing Address - Fax:972-637-7576
Practice Address - Street 1:631 CRESENT DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-8017
Practice Address - Country:US
Practice Address - Phone:469-235-2390
Practice Address - Fax:972-637-7576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health