Provider Demographics
NPI:1598461964
Name:MIND GYM LLC
Entity Type:Organization
Organization Name:MIND GYM LLC
Other - Org Name:MIND GYM NEUROFEEDBACK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-513-5092
Mailing Address - Street 1:PO BOX 21150
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-4150
Mailing Address - Country:US
Mailing Address - Phone:720-290-0154
Mailing Address - Fax:720-222-5533
Practice Address - Street 1:5350 N ACADEMY BLVD STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4055
Practice Address - Country:US
Practice Address - Phone:720-290-0154
Practice Address - Fax:720-222-5533
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIND GYM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty