Healthcare Provider Details

I. General information

NPI: 1063048668
Provider Name (Legal Business Name): MIND AND BODY WELLNESS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 VICKERY LN STE 100
CORDOVA TN
38016-0631
US

IV. Provider business mailing address

1176 VICKERY LN STE 100
CORDOVA TN
38016-0631
US

V. Phone/Fax

Practice location:
  • Phone: 901-737-1992
  • Fax:
Mailing address:
  • Phone: 901-737-1992
  • Fax: 901-309-8784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier44725
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerLICENSE

VIII. Authorized Official

Name: TONYA M MALADY
Title or Position: CREDENTIALING
Credential:
Phone: 901-737-1992