Provider Demographics
NPI:1407594153
Name:INTEGRATIVE MIND BODY THERAPY, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE MIND BODY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRACICA
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:816-752-6631
Mailing Address - Street 1:2511 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6606
Mailing Address - Country:US
Mailing Address - Phone:816-752-6631
Mailing Address - Fax:844-919-1630
Practice Address - Street 1:2511 STADIUM DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6606
Practice Address - Country:US
Practice Address - Phone:816-752-6631
Practice Address - Fax:844-919-1630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-23
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty