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General NPI Number Information
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NPI Number | 1487301891
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Entity Type | Organization
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Legal Business Name | MIND BODY INTEGRATED THERAPY, LLC
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Dates
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Enumeration Date | 03/05/2022
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Last Update Date | 10/28/2022
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Provider Practice Location Address
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Address Line | 121 N STATE ST STE 2
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City | MONTICELLO
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State | IL
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Zip | 61856-1677
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Country | US
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Telephone | 217-840-5106
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 542
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City | MONTICELLO
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State | IL
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Zip | 61856-0542
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Country | US
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Telephone | 217-840-5106
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SARA WHALEN
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Credential | LCSW
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Telephone | 217-840-5106
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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