Provider Demographics
NPI:1497273916
Name:MIND BODY SPORT, LLC
Entity Type:Organization
Organization Name:MIND BODY SPORT, LLC
Other - Org Name:DENVER MENTAL HEALTH COLLECTIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALOMBO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:720-863-6100
Mailing Address - Street 1:2121 S ONEIDA ST STE 600
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-2555
Mailing Address - Country:US
Mailing Address - Phone:720-863-6100
Mailing Address - Fax:
Practice Address - Street 1:2121 S ONEIDA ST STE 600
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-2555
Practice Address - Country:US
Practice Address - Phone:720-863-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-05
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000172843Medicaid