Provider Demographics
NPI:1679113450
Name:THE MIND EMBODIED PC
Entity Type:Organization
Organization Name:THE MIND EMBODIED PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:720-432-7654
Mailing Address - Street 1:2095 W 6TH AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1880
Mailing Address - Country:US
Mailing Address - Phone:710-432-7654
Mailing Address - Fax:
Practice Address - Street 1:2095 W 6TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1880
Practice Address - Country:US
Practice Address - Phone:710-432-7654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty