MEDICARE: MIND BODY SPIRIT THERAPIST COLLECTIVE LLC

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1881454254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND BODY SPIRIT THERAPIST COLLECTIVE LLC

Provider Business Mailing Address
First Line	:	9706 BEVERLY DR
Second Line	:
City	:	TEMPLE TERRACE
State	:	FL
Zip	:	33617-4731
Country	:	US
Telephone Number	:	813-693-2516
Fax Number	:

Provider Business Practice Location Address
First Line	:	9706 BEVERLY DR
Second Line	:
City	:	TEMPLE TERRACE
State	:	FL
Zip	:	33617-4731
Country	:	US
Telephone Number	:	813-693-2516
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHARISSE REID
Credential	:	LCSW
Telephone Number	:	813-693-2516

Provider Enumeration Date	:	03/21/2024
Last Update Date	:	03/21/2024

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