Healthcare Provider Details

I. General information

NPI: 1710929450
Provider Name (Legal Business Name): MIND BODY WELLNESS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 02/22/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17304 PRESTON RD STE 800
DALLAS TX
75252-5645
US

IV. Provider business mailing address

PO BOX 934068
MARGATE FL
33093-4068
US

V. Phone/Fax

Practice location:
  • Phone: 972-849-8987
  • Fax:
Mailing address:
  • Phone: 954-366-2700
  • Fax: 954-366-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: KRISTI ROPER
Title or Position: PARTNER
Credential: PH.D.
Phone: 214-763-1985