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General NPI Number Information
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NPI Number | 1104638519
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Entity Type | Organization
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Legal Business Name | MIND BODY SPLENDID SUN
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Dates
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Enumeration Date | 01/22/2025
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Last Update Date | 02/02/2025
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Provider Practice Location Address
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Address Line | 185 MONTREAL WAY
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City | FALLING WATERS
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State | WV
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Zip | 25419-0109
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Country | US
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Telephone | 681-242-3799
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Fax |
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Provider Business Mailing Address
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Address Line | 100 MIDDLETOWN PKWY UNIT 202
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City | MIDDLETOWN
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State | MD
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Zip | 21769-7767
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER CREDENTIALING
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Name | MICHEAL LEE
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Credential |
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Telephone | 786-791-7529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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