Provider Demographics
NPI:1376173401
Name:MOONBROOK MIND & BODY INTEGRATIVE SERVICES INCORPORATED
Entity Type:Organization
Organization Name:MOONBROOK MIND & BODY INTEGRATIVE SERVICES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:870-330-4095
Mailing Address - Street 1:4613 PARKWAY DR STE 7
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1191
Mailing Address - Country:US
Mailing Address - Phone:870-330-4095
Mailing Address - Fax:844-706-5461
Practice Address - Street 1:4613 PARKWAY DR STE 7
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1191
Practice Address - Country:US
Practice Address - Phone:870-330-4095
Practice Address - Fax:844-706-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-16
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty