Healthcare Provider Details

I. General information

NPI: 1598461964
Provider Name (Legal Business Name): MIND GYM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 N ACADEMY BLVD STE 200
COLORADO SPRINGS CO
80918-4055
US

IV. Provider business mailing address

PO BOX 21150
BOULDER CO
80308-4150
US

V. Phone/Fax

Practice location:
  • Phone: 720-290-0154
  • Fax: 720-222-5533
Mailing address:
  • Phone: 720-290-0154
  • Fax: 720-222-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LEROY MATTICKS
Title or Position: CEO
Credential:
Phone: 720-513-5092