=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316631138
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEND EMBODIED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2023
-----------------------------------------------------
Last Update Date | 06/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 SW THEATER DR
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-442-4114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 SW THEATER DR
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-442-4114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. AUTUMN STACEY MARLER
-----------------------------------------------------
Credential | LPCA
-----------------------------------------------------
Telephone | 720-442-4114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------