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General NPI Number Information
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NPI Number | 1497223846
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Entity Type | Organization
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Legal Business Name | MIND AND BODY MEDICAL CLINIC
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Dates
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Enumeration Date | 11/04/2018
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Last Update Date | 11/04/2018
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Provider Practice Location Address
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Address Line | 2216 NW 164TH ST STE A
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City | EDMOND
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State | OK
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Zip | 73013-9078
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Country | US
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Telephone | 405-285-4755
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Fax | 405-215-3760
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Provider Business Mailing Address
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Address Line | 2216 NW 164TH ST STE A
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City | EDMOND
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State | OK
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Zip | 73013-9078
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Country | US
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Telephone | 405-285-4755
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Fax | 405-215-3760
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Authorized Official
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Title or Position | CO-OWNER
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Name | KELLI LEEK
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Credential | APRN-CNS
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Telephone | 405-285-4755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0301X
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Taxonomy Name | Brain Injury Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084V0102X
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Taxonomy Name | Vascular Neurology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 364SC0200X
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Taxonomy Name | Critical Care Medicine Clinical Nurse Specialist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 364SN0800X
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Taxonomy Name | Neuroscience Clinical Nurse Specialist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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