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General NPI Number Information
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NPI Number | 1336886464
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Entity Type | Organization
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Legal Business Name | THE MIND GYM LLC
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Dates
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Enumeration Date | 05/19/2022
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Last Update Date | 07/26/2022
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Provider Practice Location Address
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Address Line | 1981 DOUBLE EAGLE DR
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City | SHERIDAN
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State | WY
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Zip | 82801-2132
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Country | US
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Telephone | 307-224-7270
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Fax |
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Provider Business Mailing Address
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Address Line | 1981 DOUBLE EAGLE DR
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City | SHERIDAN
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State | WY
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Zip | 82801-2132
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Country | US
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Telephone | 307-224-7270
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH THERAPIST
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Name | LELALELEI NOMURA
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Credential | LPC
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Telephone | 808-464-8797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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