# EMBOLDENED MIND LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1629718440
- **Authorized official:** EMBOLDENED WELLNESS THERAPEUTICS (AUTHORIZED OFFICIAL)
- **Authorized official phone:** (937) 204-3505

## Contact information

- **Practice address:** 318 REGENCY RIDGE DR, DAYTON, OH 45459-4251
- **Practice address phone:** (937) 204-3505
- **Mailing address:** 6254 WILMINGTON PIKE \# 1011, CENTERVILLE, OH 45459-7020
- **Mailing address phone:** (614) 323-0028
- **Mailing address fax:** (606) 202-7598

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2084P0800X | Psychiatry Physician | — | NULL | — |
| 2084P0800X | Psychiatry Physician | — | — | — |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 03/30/2022
- **Last updated:** 04/12/2022