NPI |
1396077566 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Entity Type Code |
2 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Employer Identification Number EIN |
|
The date that a record was last updated or changed. |
Provider Organization Name Legal Business Name |
PERSONAL ENRICHMENT THROUGH MENTAL HEALTH SERVICES, INC |
The code designating the provider’s gender if the provider is a person. |
Provider Other Organization Name |
PEMHS |
Other name by which the organization provider is or has been known. |
Provider Other Organization Name Type Code |
3 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider First Line Business Practice Location Address |
400 15TH ST N |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
ST PETERSBURG |
|
Provider Business Practice Location Address State Name |
FL |
|
Provider Business Practice Location Address Postal Code |
337052018 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
7275456477 |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Fax Number |
7275456464 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Provider Enumeration Date |
2/12/2010 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
11/12/2013 |
The date that a record was last updated or changed. |
Authorized Official Last Name |
WENNLUND |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
GERALD |
The first name of the authorized official. |
Authorized Official Title or Position |
CHEIF OPERATING OFFICER |
The title or position of the authorized official. |
Authorized Official Telephone Number |
7275456477 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
251S00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
N |
|
Authorized Official Name Prefix Text |
MR. |
|