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General NPI Number Information
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NPI Number | 1013805860
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Entity Type | Organization
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Legal Business Name | MINDGYM NEUROFEEDBACK LLC
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Dates
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Enumeration Date | 06/27/2025
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Last Update Date | 11/15/2025
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Provider Practice Location Address
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Address Line | 1123 E BROADWING LN APT 107
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City | COTTONWOOD HEIGHTS
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State | UT
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Zip | 84121-7628
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Country | US
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Telephone | 720-290-0154
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Fax |
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Provider Business Mailing Address
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Address Line | 8008 E ARAPAHOE CT STE 100
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City | CENTENNIAL
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State | CO
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Zip | 80112-6839
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Country | US
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Telephone | 720-290-0154
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LEROY MATTICKS
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Credential |
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Telephone | 720-513-5092
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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