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Organization
MIND MEDICINE CLINIC LLC
Active
Organization
MIND MEDICINE CLINIC LLC
Active
Other names
Mind Medicine Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
DR. REBECCAH S LYLES PMHNP-BC (OWNER/PROVIDER)
(312) 882-0432
Entity
Organization
Contact information
Practice address
1608 5TH ST NW, ALBUQUERQUE, NM 87102-1302
(312) 882-0432
Mailing address
1608 5TH ST NW, ALBUQUERQUE, NM 87102-1302
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1659066512
INDIVIDUAL NPI
—
05
—
545-245-63
—
NM
Enumeration date
06/28/2023
Last updated
02/16/2024
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