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General NPI Number Information
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NPI Number | 1396987046
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Entity Type | Organization
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Legal Business Name | MIND-BODY MANAGEMENT, LTD.
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Dates
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Enumeration Date | 03/26/2009
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Last Update Date | 06/15/2009
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Provider Practice Location Address
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Address Line | 108 S CHURCH ST
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City | MACUNGIE
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State | PA
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Zip | 18062-1038
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Country | US
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Telephone | 610-462-5585
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Fax | 610-966-5616
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Provider Business Mailing Address
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Address Line | 108 S CHURCH ST
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City | MACUNGIE
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State | PA
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Zip | 18062-1038
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Country | US
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Telephone | 610-462-5585
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Fax | 610-966-5616
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KELLI J DEIACO
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Credential | PHD
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Telephone | 610-462-5585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | PC004790
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License Number State | PA
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