Healthcare Provider Details

I. General information

NPI: 1154889079
Provider Name (Legal Business Name): EMBODIED RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2019
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 S SANTA CRUZ AVE STE 319
LOS GATOS CA
95030-6834
US

IV. Provider business mailing address

20 S SANTA CRUZ AVE STE 319
LOS GATOS CA
95030-6834
US

V. Phone/Fax

Practice location:
  • Phone: 888-372-3610
  • Fax:
Mailing address:
  • Phone: 888-372-3610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL NOLAN
Title or Position: PRESIDENT, COO
Credential: CADC-II
Phone: 408-705-4598