Provider Demographics
NPI:1073077111
Name:MINDBODYOLOGY FAMILY THERAPY INC
Entity Type:Organization
Organization Name:MINDBODYOLOGY FAMILY THERAPY INC
Other - Org Name:MINDBODYOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHALISS
Authorized Official - Middle Name:
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:833-444-6463
Mailing Address - Street 1:440 S MELROSE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6666
Mailing Address - Country:US
Mailing Address - Phone:833-444-6463
Mailing Address - Fax:
Practice Address - Street 1:440 S MELROSE DR STE 200
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6666
Practice Address - Country:US
Practice Address - Phone:833-444-6463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty