Provider Demographics
NPI:1346776226
Name:EMBODIED ECOLOGY GROUP
Entity Type:Organization
Organization Name:EMBODIED ECOLOGY GROUP
Other - Org Name:THE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LANGDON
Authorized Official - Middle Name:SE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-239-6353
Mailing Address - Street 1:2425 PORTER ST STE 7
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-2454
Mailing Address - Country:US
Mailing Address - Phone:831-464-1419
Mailing Address - Fax:831-476-7529
Practice Address - Street 1:2425 PORTER ST STE 7
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2454
Practice Address - Country:US
Practice Address - Phone:831-464-1419
Practice Address - Fax:831-476-7529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80304106H00000X
106H00000X, 174H00000X
CA50028172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No172M00000XOther Service ProvidersMechanotherapistGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty