Healthcare Provider Details

I. General information

NPI: 1366018129
Provider Name (Legal Business Name): MIND BODY AND SOUL A ROAD TO RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5490 BROADWAY BSMT
MERRILLVILLE IN
46410-1675
US

IV. Provider business mailing address

5490 BROADWAY BSMT
MERRILLVILLE IN
46410-1675
US

V. Phone/Fax

Practice location:
  • Phone: 219-555-5555
  • Fax:
Mailing address:
  • Phone: 219-939-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: LYNN MCDONALD
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 219-769-1670