Provider Demographics
NPI:1205401809
Name:MIND, BODY AND SPIRIT COUNSELING & CONSULTATION LLC
Entity Type:Organization
Organization Name:MIND, BODY AND SPIRIT COUNSELING & CONSULTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:PONZIANO
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC, MAC
Authorized Official - Phone:773-981-0620
Mailing Address - Street 1:2025 BLUEBERRY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6589
Mailing Address - Country:US
Mailing Address - Phone:773-981-0620
Mailing Address - Fax:
Practice Address - Street 1:2025 BLUEBERRY ST APT 2
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6589
Practice Address - Country:US
Practice Address - Phone:773-981-0620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)