MEDICARE: MIND GYM NEUROFEEDBACK, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1023825775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND GYM NEUROFEEDBACK, LLC

Provider Business Mailing Address
First Line	:	5322 PRIMROSE LAKE CIR STE H
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3659
Country	:	US
Telephone Number	:	720-305-6583
Fax Number	:	720-222-5533

Provider Business Practice Location Address
First Line	:	730 S STERLING AVE STE 301
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4524
Country	:	US
Telephone Number	:	720-305-6583
Fax Number	:	720-222-5533

Authorized Official
Title or Position	:	CEO
Name	:	MR. LEROY MATTICKS
Credential	:
Telephone Number	:	720-290-0154

Provider Enumeration Date	:	12/16/2024
Last Update Date	:	12/16/2024

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