Healthcare Provider Details

I. General information

NPI: 1366109795
Provider Name (Legal Business Name): EMBODIED MIND MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 CONCORD AVE APT 2C
CAMBRIDGE MA
02138-1398
US

IV. Provider business mailing address

263 CONCORD AVE APT 2C
CAMBRIDGE MA
02138-1398
US

V. Phone/Fax

Practice location:
  • Phone: 617-902-0454
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RHEINILA FERNANDES
Title or Position: PSYHIATRIST
Credential: MD
Phone: 617-902-0454