Provider Demographics
NPI:1629718440
Name:EMBOLDENED MIND LLC
Entity Type:Organization
Organization Name:EMBOLDENED MIND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:EMBOLDENED WELLNESS
Authorized Official - Middle Name:
Authorized Official - Last Name:THERAPEUTICS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-204-3505
Mailing Address - Street 1:6254 WILMINGTON PIKE # 1011
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7020
Mailing Address - Country:US
Mailing Address - Phone:614-323-0028
Mailing Address - Fax:606-202-7598
Practice Address - Street 1:318 REGENCY RIDGE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4251
Practice Address - Country:US
Practice Address - Phone:937-204-3505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-30
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty