Wisdom Psychiatric Care and Medication Management LLC

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

WISDOM PSYCHIATRIC CARE AND MEDICATION MANAGEMENT LLC

Practice address

2704 Mounds View Blvd
Ste 12
Mounds View, MN 55112

Phone

(320) 232-0647

Fax

(567) 205-3614

NPI assigned

Feb 23, 2021

Last updated

Feb 17, 2022By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Melodie Anne Kabanuk Dohm, APRN-CNP, PMHNPNPI 1578029757

Title

Owner/Provider

Phone

(320) 232-0647

Specialties & licenses 2

Addresses

Other identifiers 1

Electronic endpoints 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Melodie Anne Kabanuk Dohm, APRN-CNP, PMHNP

  • Psychiatric/Mental Health Nurse Practitioner
  • Saint Paul, MN
  • NPI 1578029757
  NPD Authorized official

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

{
    "created_epoch": "1614038400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1645056000000",
    "number": "1255925962",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8628 HASTINGS ST NE",
            "city": "BLAINE",
            "state": "MN",
            "postal_code": "554494252",
            "telephone_number": "320-232-0647",
            "fax_number": "567-205-3614"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2704 MOUNDS VIEW BLVD",
            "address_2": "STE 12",
            "city": "MOUNDS VIEW",
            "state": "MN",
            "postal_code": "55112",
            "telephone_number": "320-232-0647",
            "fax_number": "567-205-3614"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WISDOM PSYCHIATRIC CARE AND MEDICATION MANAGEMENT LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-02-23",
        "last_updated": "2022-02-17",
        "certification_date": "2022-02-17",
        "status": "A",
        "authorized_official_last_name": "KABANUK DOHM",
        "authorized_official_first_name": "MELODIE",
        "authorized_official_middle_name": "ANNE",
        "authorized_official_title_or_position": "OWNER/PROVIDER",
        "authorized_official_telephone_number": "320-232-0647",
        "authorized_official_credential": "APRN-CNP, PMHNP"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "359498100",
            "state": "MN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "support@wisdom-clinic.com",
            "affiliation": "N",
            "endpointDescription": "HIPPA compliant email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "2704 Mounds View Blvd",
            "address_2": "STE 12",
            "city": "Mounds View",
            "state": "MN",
            "country_code": "US",
            "postal_code": "55112",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Mental Health Clinic/Center (Including Community Mental Health Center) in Mounds View, MN
• Providers in Mounds View, MN by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.