{
"Npi": {
"NPI": "1598391229",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MIND AND BODY WELLNESS LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6825 WHITE EGRET CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "TINLEY PARK",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "60477-3973",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "630-546-2465",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "6825 WHITE EGRET CT",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "TINLEY PARK",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "60477-3973",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "630-546-2465",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/13/2020",
"LastUpdateDate": "11/04/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "NELSON",
"AuthorizedOfficialFirstName": "TALIA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "708-260-2030",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "363LP0808X",
"TaxonomyName": "Psychiatric/Mental Health Nurse Practitioner",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}