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General NPI Number Information
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NPI Number | 1356054423
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Entity Type | Organization
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Legal Business Name | THE GORDIAN MIND
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Dates
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Enumeration Date | 01/03/2023
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 296 W. SUNSET AVE STE 15
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City | COEUR D ALENE
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State | ID
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Zip | 83815-8366
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Country | US
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Telephone | 208-666-0357
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Fax | 208-666-0468
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Provider Business Mailing Address
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Address Line | 296 W. SUNSET AVE STE 15
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City | COEUR D ALENE
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State | ID
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Zip | 83815-8366
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Country | US
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Telephone | 208-666-0357
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Fax | 208-666-0468
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Authorized Official
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Title or Position | OWNER
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Name | JILL BREITBACH
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Credential | PSYD
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Telephone | 208-666-0357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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