MEDICARE: MIND & BODY PSYCHOTHERAPY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1215632476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND & BODY PSYCHOTHERAPY INC

Provider Business Mailing Address
First Line	:	1026 W EL NORTE PKWY # 48
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92026-3341
Country	:	US
Telephone Number	:	619-395-2885
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 E GRAND AVE STE 2A
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-2818
Country	:	US
Telephone Number	:	619-395-2885
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PSYCHOLOGIST
Name	:	DR. LEANNE SELF
Credential	:	PSY.D.
Telephone Number	:	619-395-2885

Provider Enumeration Date	:	04/04/2023
Last Update Date	:	04/04/2023

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