Healthcare Provider Details

I. General information

NPI: 1679113450
Provider Name (Legal Business Name): THE MIND EMBODIED PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 CANYON BLVD STE 200
BOULDER CO
80302-4954
US

IV. Provider business mailing address

255 CANYON BLVD STE 200
BOULDER CO
80302-4954
US

V. Phone/Fax

Practice location:
  • Phone: 720-432-7654
  • Fax:
Mailing address:
  • Phone: 720-432-7654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CAROLINE LEACH
Title or Position: CO-OWNER, SECRETARY
Credential: MA, LPC
Phone: 720-432-7654