Healthcare Provider Details

I. General information

NPI: 1093336505
Provider Name (Legal Business Name): MIND BODY THERAPEUTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 SE WILLOUGHBY BLVD STE 2B
STUART FL
34994-4700
US

IV. Provider business mailing address

2630 SE WILLOUGHBY BLVD STE 2B
STUART FL
34994-4700
US

V. Phone/Fax

Practice location:
  • Phone: 954-303-8558
  • Fax:
Mailing address:
  • Phone: 954-303-8558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JANE B STATLANDER-SLOTE
Title or Position: OWNER
Credential: LSW
Phone: 305-331-4489