Provider Demographics
NPI:1982468633
Name:EMBODIED PERFORMANCE, LLC
Entity type:Organization
Organization Name:EMBODIED PERFORMANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'HANA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC, ACS
Authorized Official - Phone:541-515-5213
Mailing Address - Street 1:61141 S HWY 97
Mailing Address - Street 2:PMB 162
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2523
Mailing Address - Country:US
Mailing Address - Phone:541-515-5213
Mailing Address - Fax:
Practice Address - Street 1:61690 PETTIGREW RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2422
Practice Address - Country:US
Practice Address - Phone:541-515-5213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional