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General NPI Number Information
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NPI Number | 1053779207
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Entity Type | Organization
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Legal Business Name | BODHI LEAF, PLLC
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Dates
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Enumeration Date | 02/03/2016
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Last Update Date | 02/03/2016
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Provider Practice Location Address
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Address Line | 1300 WEST LYNN DRIVE SUITE 207
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City | AUSTIN
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State | TX
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Zip | 78703
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Country | US
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Telephone | 512-653-4623
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Fax |
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Provider Business Mailing Address
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Address Line | 204 E 34TH ST APT B
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City | AUSTIN
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State | TX
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Zip | 78705-1665
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Country | US
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Telephone | 512-653-4623
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | SASHI GABRIELLE KIMBALL
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Credential | LCSW
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Telephone | 512-653-4623
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 57473
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License Number State | TX
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