Provider Demographics
NPI:1366018129
Name:MIND BODY AND SOUL A ROAD TO RECOVERY
Entity Type:Organization
Organization Name:MIND BODY AND SOUL A ROAD TO RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-769-1670
Mailing Address - Street 1:5490 BROADWAY BSMT
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-1675
Mailing Address - Country:US
Mailing Address - Phone:219-939-7763
Mailing Address - Fax:
Practice Address - Street 1:5490 BROADWAY BSMT
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-1675
Practice Address - Country:US
Practice Address - Phone:219-555-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-02
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty