Provider Demographics
NPI:1588471239
Name:MIND GYM NEUROFEEDBACK, LLC
Entity type:Organization
Organization Name:MIND GYM NEUROFEEDBACK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-290-0154
Mailing Address - Street 1:5322 PRIMROSE LAKE CIR STE H
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3659
Mailing Address - Country:US
Mailing Address - Phone:720-233-2299
Mailing Address - Fax:
Practice Address - Street 1:5322 PRIMROSE LAKE CIR STE H
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3659
Practice Address - Country:US
Practice Address - Phone:720-233-2299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty