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General NPI Number Information
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NPI Number | 1558183723
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Entity Type | Organization
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Legal Business Name | MIND/BODY INSTITUTE, LLC
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Dates
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Enumeration Date | 10/29/2024
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 3511 CENTER RD STE J
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City | BRUNSWICK
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State | OH
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Zip | 44212-3693
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Country | US
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Telephone | 330-510-5221
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Fax | 330-510-5228
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Provider Business Mailing Address
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Address Line | 3511 CENTER RD STE J
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City | BRUNSWICK
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State | OH
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Zip | 44212-3693
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Country | US
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Telephone | 330-510-5221
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Fax | 330-510-5228
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Authorized Official
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Title or Position | DIRECTOR OF CLINICAL OPERATIONS
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Name | DERRICK MARTIN
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Credential | LPCC-S
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Telephone | 330-510-5221
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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 |
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License Number State |
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