=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992971675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDBODY WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2008
-----------------------------------------------------
Last Update Date | 05/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 S ELLIOTT AVE SUITE B
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65605-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-440-0826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1407 S ELLIOTT AVE SUITE B
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65605-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-440-0826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. STACEY L. WILLIS-CENTER
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 417-440-0826
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2008007986
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------