Functional Mental Health LLC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

Legal business name

FUNCTIONAL MENTAL HEALTH LLC

Practice address

11 SW Brantley Dr
Winston, OR 97496-4526

Phone

(541) 679-0366

Fax

(541) 679-4821

NPI assigned

May 20, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

McKenzie SmithNPI 1932551165

Title

Pmhnp

Phone

(541) 326-8078

Specialties & licenses 1

Addresses

Other names 1

• Functional Mental Health LLC Doing business as

Medicare fee-for-service enrollment

Enrolled in OR

Enrollment records 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• McKenzie Smith

  • Psychiatric/Mental Health Nurse Practitioner
  • Grants Pass, OR
  • NPI 1932551165
  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1589932800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611705600000",
    "number": "1154944536",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 SW BRANTLEY DR",
            "city": "WINSTON",
            "state": "OR",
            "postal_code": "974964526",
            "telephone_number": "541-679-0366",
            "fax_number": "541-679-4821"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11 SW BRANTLEY DR",
            "city": "WINSTON",
            "state": "OR",
            "postal_code": "974964526",
            "telephone_number": "541-679-0366",
            "fax_number": "541-679-4821"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FUNCTIONAL MENTAL HEALTH LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-05-20",
        "last_updated": "2021-01-27",
        "certification_date": "2021-01-14",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "MCKENZIE",
        "authorized_official_title_or_position": "PMHNP",
        "authorized_official_telephone_number": "541-326-8078"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Functional Mental Health LLC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Functional Mental Health LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Suzanne Ruth Dudek Dewbre, FNP-C
• Rebecca Lin Duffy, RN
• Julia C Edwards
• Laecey Mae Foster
• Kimie Ann Frakes, LCSW
• Jennie L Gohman, NP
• Amanda Alice Gray, RDH
• Harold Timothy Hall, DDS
• Jaime Hansen, FNP-C, FNP-BC
• Cora G Hart, PHD

• Psychiatric/Mental Health Nurse Practitioner in Winston, OR
• Providers in Winston, OR by specialty
• Psychiatric/Mental Health Nurse Practitioner in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.