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General NPI Number Information
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NPI Number | 1124364104
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Entity Type | Organization
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Legal Business Name | MINDBODY CONNECTION
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Dates
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Enumeration Date | 12/20/2012
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Last Update Date | 12/20/2012
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Provider Practice Location Address
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Address Line | 2875 NE 191ST ST #538
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City | AVENTURA
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State | FL
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Zip | 33180-2801
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Country | US
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Telephone | 754-300-9386
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Fax | 786-923-0947
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Provider Business Mailing Address
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Address Line | 2121 SW 3RD AVE 200
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City | MIAMI
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State | FL
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Zip | 33129-1490
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Country | US
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Telephone | 786-553-4546
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Fax | 786-923-0947
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. MARIAM DUM
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Credential | PH.D.
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Telephone | 786-553-4546
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY 8498
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License Number State | FL
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