Provider Demographics
NPI:1427374024
Name:BODYMIND THERAPEUTICS, INC.
Entity Type:Organization
Organization Name:BODYMIND THERAPEUTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:H
Authorized Official - Last Name:CECCOLI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-838-9806
Mailing Address - Street 1:8014 LONGLEAF DR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-8666
Mailing Address - Country:US
Mailing Address - Phone:770-838-9806
Mailing Address - Fax:770-834-9188
Practice Address - Street 1:415 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3921
Practice Address - Country:US
Practice Address - Phone:770-838-9806
Practice Address - Fax:770-834-9188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC5686101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty