Healthcare Provider Details

I. General information

NPI: 1679403737
Provider Name (Legal Business Name): MIND BODY SPIRIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 SARNO RD STE C
MELBOURNE FL
32935-5214
US

IV. Provider business mailing address

1380 SARNO RD STE C
MELBOURNE FL
32935-5214
US

V. Phone/Fax

Practice location:
  • Phone: 802-391-9104
  • Fax:
Mailing address:
  • Phone: 802-391-9104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN MARTIN POWELL
Title or Position: SOLE OWNER
Credential: M.S.,LMHC, NCC, QS
Phone: 802-391-9104