Telemental Health Link LLC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

Legal business name

TELEMENTAL HEALTH LINK LLC

Doing business as

TELEMENTAL HEALTH LINK - NM

Practice address

4055 E Blueberry St
Meridian, ID 83642-8261

Phone

(208) 775-7418

Fax

(208) 647-5008

NPI assigned

Feb 27, 2020

Organization subpart

Yes

Parent organization

PSYCHIATRIC NURSE PRACTITIONER SERVICES LLCAs reported in NPPES

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

Authorized official

Name

Susan M Derivas, PMHNP-BC

Title

Ao

Phone

(208) 775-7418

Specialties & licenses 2

Addresses

Other identifiers 11

Other names 2

• TELEMENTAL HEALTH LINK - NM Doing business as
• Psychiatric Nurse Practitioner Services LLC Former legal business name

Part of

Psychiatric Nurse Practitioner Services LLC

Locations

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

{
    "created_epoch": "1582761600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707264000000",
    "number": "1437783529",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4055 E BLUEBERRY ST",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836428261",
            "telephone_number": "208-600-2060",
            "fax_number": "208-647-5008"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4055 E BLUEBERRY ST",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836428261",
            "telephone_number": "208-775-7418",
            "fax_number": "208-647-5008"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "10173 Trailridge Dr",
            "address_purpose": "LOCATION",
            "city": "Shreveport",
            "state": "LA",
            "postal_code": "711067651",
            "country_code": "US",
            "telephone_number": "208-600-2060",
            "fax_number": "208-647-5008",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "5700 Harper Dr NE Ste 210",
            "address_purpose": "LOCATION",
            "city": "Albuquerque",
            "state": "NM",
            "postal_code": "871093541",
            "country_code": "US",
            "telephone_number": "866-589-1753",
            "fax_number": "208-647-5008",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "TELEMENTAL HEALTH LINK LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PSYCHIATRIC NURSE PRACTITIONER SERVICES LLC",
        "enumeration_date": "2020-02-27",
        "last_updated": "2024-02-07",
        "certification_date": "2024-02-07",
        "status": "A",
        "authorized_official_last_name": "DERIVAS",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "AO",
        "authorized_official_telephone_number": "208-775-7418",
        "authorized_official_credential": "PMHNP-BC"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CHANGE HEALTHCARE MASTER BILLING ID",
            "identifier": "396453OSMIND",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NURSING LICENSE",
            "identifier": "58322",
            "state": "NM"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NEW MEXICO APRN CNP LICENSE",
            "identifier": "58322",
            "state": "NM"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "020837",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH ID",
            "identifier": "13961493",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NURSING LICENSE",
            "identifier": "64266",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NURSING LICENSE",
            "identifier": "03962",
            "state": "LA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCSBN ID",
            "identifier": "1529234",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANCC CERTIFICATION NO.",
            "identifier": "0364158",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAXONOMIES: NURSE PRACTITIONER PSYCH MENTAL HEALTH",
            "identifier": "363LP0808X",
            "state": "LA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UPIN",
            "identifier": "P69441",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "TELEMENTAL HEALTH LINK - NM",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Psychiatric Nurse Practitioner Services LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• Psychiatric/Mental Health Nurse Practitioner in Meridian, ID
• Providers in Meridian, ID by specialty
• Psychiatric/Mental Health Nurse Practitioner in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 7, 2024; 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.