Healthcare Provider Details

I. General information

NPI: 1649518515
Provider Name (Legal Business Name): MIND BODY CONNECTIONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 08/19/2023
Certification Date: 08/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24W788 75TH ST
NAPERVILLE IL
60565-1684
US

IV. Provider business mailing address

3S101 ROCKWELL ST UNIT 247
WARRENVILLE IL
60555-2948
US

V. Phone/Fax

Practice location:
  • Phone: 312-543-2133
  • Fax:
Mailing address:
  • Phone: 312-543-2133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number180-003221
License Number StateIL

VIII. Authorized Official

Name: STACEY M HURST
Title or Position: OWNER
Credential: LCPC
Phone: 312-543-2133