Healthcare Provider Details

I. General information

NPI: 1093457921
Provider Name (Legal Business Name): BRAIN HEALTH SALON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 03/04/2023
Certification Date: 03/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 GORDON AVE NW
CEDAR RAPIDS IA
52405-3307
US

IV. Provider business mailing address

5020 GORDON AVE NW
CEDAR RAPIDS IA
52405-3307
US

V. Phone/Fax

Practice location:
  • Phone: 505-306-4642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
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: SANDRA LEIGH
Title or Position: OWNER
Credential:
Phone: 505-289-1129