Healthcare Provider Details

I. General information

NPI: 1295519213
Provider Name (Legal Business Name): MIND BODY CONNECTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 BLACK HAWK RD STE 4
BLACK HAWK SD
57718-3315
US

IV. Provider business mailing address

8000 BLACK HAWK RD STE 4
BLACK HAWK SD
57718-3315
US

V. Phone/Fax

Practice location:
  • Phone: 605-431-3388
  • Fax:
Mailing address:
  • Phone: 605-431-3388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: JESSICA KOUPAL
Title or Position: BUSINESS OWNER
Credential: DNP-FNP, QMHP, PMHNP
Phone: 605-431-3388