Provider Demographics
NPI:1497223846
Name:MIND AND BODY MEDICAL CLINIC
Entity Type:Organization
Organization Name:MIND AND BODY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEEK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNS
Authorized Official - Phone:405-285-4755
Mailing Address - Street 1:2216 NW 164TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-9078
Mailing Address - Country:US
Mailing Address - Phone:405-285-4755
Mailing Address - Fax:405-215-3760
Practice Address - Street 1:2216 NW 164TH ST STE A
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-9078
Practice Address - Country:US
Practice Address - Phone:405-285-4755
Practice Address - Fax:405-215-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No2084P0301XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBrain Injury MedicineGroup - Single Specialty
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Single Specialty
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care MedicineGroup - Single Specialty
No364SN0800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeuroscienceGroup - Single Specialty