Provider Demographics
NPI:1790324747
Name:EMBODIED HEART MIND LLC
Entity Type:Organization
Organization Name:EMBODIED HEART MIND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/APN
Authorized Official - Prefix:
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-358-5558
Mailing Address - Street 1:PO BOX 2264
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-9064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 SCOTCH RD
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-2529
Practice Address - Country:US
Practice Address - Phone:973-358-5558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-22
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)