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General NPI Number Information
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NPI Number | 1629718440
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Entity Type | Organization
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Legal Business Name | EMBOLDENED MIND LLC
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Dates
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Enumeration Date | 03/30/2022
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Last Update Date | 04/12/2022
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Provider Practice Location Address
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Address Line | 318 REGENCY RIDGE DR
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City | DAYTON
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State | OH
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Zip | 45459-4251
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Country | US
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Telephone | 937-204-3505
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Fax |
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Provider Business Mailing Address
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Address Line | 6254 WILMINGTON PIKE # 1011
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City | CENTERVILLE
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State | OH
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Zip | 45459-7020
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Country | US
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Telephone | 614-323-0028
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Fax | 606-202-7598
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | EMBOLDENED WELLNESS THERAPEUTICS
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Credential |
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Telephone | 937-204-3505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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