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General NPI Number Information
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NPI Number | 1922897917
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Entity Type | Organization
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Legal Business Name | MIND BODY MIRROR LLC
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Dates
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Enumeration Date | 05/05/2025
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Last Update Date | 05/05/2025
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Provider Practice Location Address
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Address Line | 9000 QUANTRELLE AVE NE
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City | OTSEGO
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State | MN
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Zip | 55330-1022
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Country | US
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Telephone | 219-595-2121
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Fax |
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Provider Business Mailing Address
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Address Line | 8808 373RD AVE NW
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City | PRINCETON
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State | MN
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Zip | 55371-5512
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Country | US
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Telephone | 651-210-4020
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | REBECCA MICHELLE ANDERSON
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Credential |
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Telephone | 219-595-2121
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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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