Provider Demographics
NPI:1497045918
Name:MIND-BODY CONNECTION, LLC
Entity Type:Organization
Organization Name:MIND-BODY CONNECTION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPICUZZA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, ONS
Authorized Official - Phone:781-821-7477
Mailing Address - Street 1:401 NEPONSET ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-1937
Mailing Address - Country:US
Mailing Address - Phone:781-821-7477
Mailing Address - Fax:781-821-7447
Practice Address - Street 1:401 NEPONSET ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-1937
Practice Address - Country:US
Practice Address - Phone:781-821-7477
Practice Address - Fax:781-821-7447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17793208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty