Healthcare Provider Details

I. General information

NPI: 1407208390
Provider Name (Legal Business Name): CLEAR MIND THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W BROADWAY STE 706
COUNCIL BLUFFS IA
51503-4489
US

IV. Provider business mailing address

300 W BROADWAY STE 706
COUNCIL BLUFFS IA
51503-4489
US

V. Phone/Fax

Practice location:
  • Phone: 712-256-9902
  • Fax: 712-256-9903
Mailing address:
  • Phone: 712-256-9902
  • Fax: 712-256-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001147
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007763
License Number StateIA

VIII. Authorized Official

Name: CIARA WARDEN
Title or Position: CO OWNER
Credential: LISW
Phone: 712-256-9902