Healthcare Provider Details

I. General information

NPI: 1740045004
Provider Name (Legal Business Name): MIND, BODY & SOUL PSYCHIATRY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4393 HUNTING TRL
LAKE WORTH FL
33467-3505
US

IV. Provider business mailing address

4393 HUNTING TRL
LAKE WORTH FL
33467-3505
US

V. Phone/Fax

Practice location:
  • Phone: 954-546-2707
  • Fax: 954-820-5592
Mailing address:
  • Phone: 954-546-2707
  • Fax: 954-820-5592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DIANA SOFIA GLACCUM-GAVAGNI
Title or Position: OWNER/PSYCHIATRIST
Credential: MD
Phone: 954-546-2707