MEDICARE: MIND & BODY REBOOT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1041C0700X	OTHER	PA	HIGHMARK

General Provider Information

NPI Number	:	1760144901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND & BODY REBOOT, LLC

Provider Business Mailing Address
First Line	:	10 GREGORY LN
Second Line	:
City	:	CHESTER SPRINGS
State	:	PA
Zip	:	19425-3314
Country	:	US
Telephone Number	:	610-213-4101
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 GREGORY LN
Second Line	:
City	:	CHESTER SPRINGS
State	:	PA
Zip	:	19425-3314
Country	:	US
Telephone Number	:	610-465-7310
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	DR. LISA CERRULLO
Credential	:	PHD
Telephone Number	:	610-465-7310

Provider Enumeration Date	:	10/05/2021
Last Update Date	:	10/05/2021

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Directions to “MIND & BODY REBOOT, LLC ” Practice Location

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