Healthcare Provider Details

I. General information

NPI: 1679108617
Provider Name (Legal Business Name): MIND GYM CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 E ARAPAHOE CT STE 100
CENTENNIAL CO
80112-6839
US

IV. Provider business mailing address

8008 E ARAPAHOE CT STE 100
CENTENNIAL CO
80112-6839
US

V. Phone/Fax

Practice location:
  • Phone: 719-457-6200
  • Fax:
Mailing address:
  • Phone: 719-457-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHELLI MYLES
Title or Position: PROVIDER
Credential: MAC CACREP
Phone: 719-457-6200