Provider Demographics
NPI:1356054423
Name:THE GORDIAN MIND
Entity type:Organization
Organization Name:THE GORDIAN MIND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BREITBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:208-666-0357
Mailing Address - Street 1:296 W. SUNSET AVE
Mailing Address - Street 2:STE 15
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8366
Mailing Address - Country:US
Mailing Address - Phone:208-666-0357
Mailing Address - Fax:208-666-0468
Practice Address - Street 1:296 W. SUNSET AVE
Practice Address - Street 2:STE 15
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8366
Practice Address - Country:US
Practice Address - Phone:208-666-0357
Practice Address - Fax:208-666-0468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-03
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center