MEDICARE: COLLECTIVE MIND THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1154005767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLECTIVE MIND THERAPY

Provider Business Mailing Address
First Line	:	1120 SPARKLING POINT AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-2437
Country	:	US
Telephone Number	:	310-500-5645
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 SPARKLING POINT AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-2437
Country	:	US
Telephone Number	:	310-500-5645
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. TONY MARTINEZ
Credential	:	LMFT
Telephone Number	:	310-500-5645

Provider Enumeration Date	:	06/14/2023
Last Update Date	:	06/14/2023

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