Healthcare Provider Details

I. General information

NPI: 1659017770
Provider Name (Legal Business Name): MIND BODY NUTRITION COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S HOWES ST STE BLDGA104
FORT COLLINS CO
80521-2871
US

IV. Provider business mailing address

3345 W ELIZABETH ST
FORT COLLINS CO
80521-3479
US

V. Phone/Fax

Practice location:
  • Phone: 970-980-8732
  • Fax:
Mailing address:
  • Phone: 605-214-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY STOKER
Title or Position: OWNER
Credential: RDN, LPCC
Phone: 970-980-8732