Provider Demographics
NPI:1750004370
Name:EMBODY & MIND COLLECTIVE
Entity type:Organization
Organization Name:EMBODY & MIND COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:TESA
Authorized Official - Middle Name:
Authorized Official - Last Name:EMMART
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LMHC
Authorized Official - Phone:773-309-1542
Mailing Address - Street 1:53 W JACKSON BLVD STE 1334
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3548
Mailing Address - Country:US
Mailing Address - Phone:773-309-1542
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 1334
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3548
Practice Address - Country:US
Practice Address - Phone:773-309-1542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty