Healthcare Provider Details

I. General information

NPI: 1932419413
Provider Name (Legal Business Name): MIND BODY SOULUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12802 W HAMPTON AVE
BUTLER WI
53007-1606
US

IV. Provider business mailing address

12802 W HAMPTON AVE
BUTLER WI
53007-1606
US

V. Phone/Fax

Practice location:
  • Phone: 262-327-6381
  • Fax:
Mailing address:
  • Phone: 262-327-6381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. CYNTHIA L. SOLLIDAY
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 262-327-6381