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General NPI Number Information
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NPI Number | 1679198444
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Entity Type | Organization
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Legal Business Name | MIND BODY & SOUL CONNECTION LLC
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Dates
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Enumeration Date | 06/08/2020
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Last Update Date | 06/08/2020
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Provider Practice Location Address
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Address Line | 119 PERE MARQUETTE DR STE 3C
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City | LANSING
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State | MI
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Zip | 48912-1270
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Country | US
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Telephone | 517-455-7555
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Fax | 517-455-7540
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Provider Business Mailing Address
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Address Line | 13185 WACOUSTA RD
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City | GRAND LEDGE
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State | MI
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Zip | 48837-9254
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Country | US
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Telephone | 734-674-2515
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST MASTERS LEVEL
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Name | JACKIE SHPAK
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Credential | LLP
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Telephone | 734-674-2515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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