Healthcare Provider Details

I. General information

NPI: 1679198444
Provider Name (Legal Business Name): MIND BODY & SOUL CONNECTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13185 WACOUSTA RD
GRAND LEDGE MI
48837-9254
US

IV. Provider business mailing address

13185 WACOUSTA RD
GRAND LEDGE MI
48837-9254
US

V. Phone/Fax

Practice location:
  • Phone: 734-674-2515
  • Fax:
Mailing address:
  • Phone: 734-674-2515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JACKIE SHPAK
Title or Position: PSYCHOLOGIST MASTERS LEVEL
Credential: LLP
Phone: 734-674-2515