=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194479147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND, BODY, SOULMATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2022
-----------------------------------------------------
Last Update Date | 02/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7405 W ARIZONA PL
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80232-5416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-371-9404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7405 W ARIZONA PL
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80232-5416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-371-9404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ISABLE MARIE SMITH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 970-371-9404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------