Provider Demographics
NPI:1336886464
Name:THE MIND GYM LLC
Entity Type:Organization
Organization Name:THE MIND GYM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LELALELEI
Authorized Official - Middle Name:
Authorized Official - Last Name:NOMURA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:808-464-8797
Mailing Address - Street 1:1981 DOUBLE EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2132
Mailing Address - Country:US
Mailing Address - Phone:307-224-7270
Mailing Address - Fax:
Practice Address - Street 1:1981 DOUBLE EAGLE DR
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2132
Practice Address - Country:US
Practice Address - Phone:307-224-7270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-19
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty