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General NPI Number Information
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NPI Number | 1578974143
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Entity Type | Organization
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Legal Business Name | MIND BODY PROFESSIONAL CENTER
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Dates
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Enumeration Date | 05/16/2014
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Last Update Date | 05/16/2014
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Provider Practice Location Address
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Address Line | 15406 MERIDIAN E STE 103
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City | PUYALLUP
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State | WA
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Zip | 98375-9504
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Country | US
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Telephone | 253-278-9292
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Fax | 253-604-6237
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Provider Business Mailing Address
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Address Line | PO BOX 1331
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City | PUYALLUP
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State | WA
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Zip | 98371-0243
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Country | US
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Telephone | 253-278-9292
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Fax | 253-604-6237
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Authorized Official
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Title or Position | MANAGER
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Name | REBECCA LYNN BEUTLER
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Credential | EDD
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Telephone | 253-278-9292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | PY60318110
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License Number State | WA
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