Provider Demographics
NPI:1154889079
Name:EMBODIED RECOVERY, LLC
Entity type:Organization
Organization Name:EMBODIED RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:CADC-II
Authorized Official - Phone:408-705-4598
Mailing Address - Street 1:20 S SANTA CRUZ AVE STE 319
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-6834
Mailing Address - Country:US
Mailing Address - Phone:888-372-3610
Mailing Address - Fax:
Practice Address - Street 1:20 S SANTA CRUZ AVE STE 319
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-6834
Practice Address - Country:US
Practice Address - Phone:888-372-3610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-10
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA011980315OtherCCAPP
CA97049OtherBBS