Organization
WISDOM PSYCHIATRIC CARE AND MEDICATION MANAGEMENT LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MELODIE ANNE KABANUK DOHM APRN-CNP, PMHNP (OWNER/PROVIDER)
(320) 232-0647
Entity
Organization
Contact information
Practice address
2704 MOUNDS VIEW BLVD, STE 12, MOUNDS VIEW, MN 55112
(320) 232-0647
(567) 205-3614
Mailing address
8628 HASTINGS ST NE, BLAINE, MN 55449-4252
(320) 232-0647
(567) 205-3614
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
359498100
—
MN
Enumeration date
02/23/2021
Last updated
02/17/2022
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