Healthcare Provider Details

I. General information

NPI: 1538029988
Provider Name (Legal Business Name): MINDBODYMOM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/17/2025
Certification Date: 11/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1636 W STEVANNA WAY UNITED STATES
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

16192 COASTAL HWY
LEWES DE
19958-3608
US

V. Phone/Fax

Practice location:
  • Phone: 970-471-3981
  • Fax:
Mailing address:
  • Phone: 970-471-3981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMANTHA C RUSSELL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHD
Phone: 970-471-3981