Healthcare Provider Details

I. General information

NPI: 1356054423
Provider Name (Legal Business Name): THE GORDIAN MIND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 W. SUNSET AVE STE 15
COEUR D ALENE ID
83815-8366
US

IV. Provider business mailing address

296 W. SUNSET AVE STE 15
COEUR D ALENE ID
83815-8366
US

V. Phone/Fax

Practice location:
  • Phone: 208-666-0357
  • Fax: 208-666-0468
Mailing address:
  • Phone: 208-666-0357
  • Fax: 208-666-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JILL BREITBACH
Title or Position: OWNER
Credential: PSYD
Phone: 208-666-0357