Provider Demographics
NPI:1376287896
Name:BODY & SOUL MFR THERAPY LLC
Entity Type:Organization
Organization Name:BODY & SOUL MFR THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDER HEIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:920-209-0012
Mailing Address - Street 1:121 W TOWN RD
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:WI
Mailing Address - Zip Code:54162-9278
Mailing Address - Country:US
Mailing Address - Phone:920-209-0012
Mailing Address - Fax:
Practice Address - Street 1:110 PACKERLAND DR STE C2
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4861
Practice Address - Country:US
Practice Address - Phone:920-209-0012
Practice Address - Fax:920-888-2409
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BODY & SOUL MFR THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-21
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty