Healthcare Provider Details

I. General information

NPI: 1164804977
Provider Name (Legal Business Name): BODY MIND SPIRIT THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 EAST ATLANTIC AVENUE SUITE 205
DELRAY BEACH FL
33483
US

IV. Provider business mailing address

1045 EAST ATLANTIC AVENUE SUITE 205
DELRAY BEACH FL
33483
US

V. Phone/Fax

Practice location:
  • Phone: 561-727-6858
  • Fax: 561-330-4264
Mailing address:
  • Phone: 561-727-6858
  • Fax: 561-330-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT1988
License Number StateFL

VIII. Authorized Official

Name: MS. KELLY PIERCE PINEDA
Title or Position: PRESIDENT/DIRECTOR
Credential: LMFT
Phone: 561-727-6858