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General NPI Number Information
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NPI Number | 1598461964
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Entity Type | Organization
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Legal Business Name | MIND GYM LLC
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Dates
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Enumeration Date | 02/06/2023
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Last Update Date | 02/06/2023
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Provider Practice Location Address
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Address Line | 5350 N ACADEMY BLVD STE 200
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City | COLORADO SPRINGS
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State | CO
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Zip | 80918-4055
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Country | US
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Telephone | 720-290-0154
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Fax | 720-222-5533
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Provider Business Mailing Address
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Address Line | PO BOX 21150
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City | BOULDER
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State | CO
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Zip | 80308-4150
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Country | US
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Telephone | 720-290-0154
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Fax | 720-222-5533
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Authorized Official
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Title or Position | CEO
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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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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