Provider Demographics
NPI:1649816588
Name:EMBODIMENT THERAPY LLC
Entity type:Organization
Organization Name:EMBODIMENT THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:865-368-5298
Mailing Address - Street 1:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:RONAN
Mailing Address - State:MT
Mailing Address - Zip Code:59864-0423
Mailing Address - Country:US
Mailing Address - Phone:865-368-5298
Mailing Address - Fax:406-571-4008
Practice Address - Street 1:63917 US HIGHWAY 93
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-3411
Practice Address - Country:US
Practice Address - Phone:865-368-5298
Practice Address - Fax:406-571-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-26
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1578063616Medicaid