Provider Demographics
NPI:1508222688
Name:MIND BODY CONNECTION LLC
Entity Type:Organization
Organization Name:MIND BODY CONNECTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTINI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MHSP NCC
Authorized Official - Phone:615-369-9897
Mailing Address - Street 1:PO BOX 330931
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37133-0931
Mailing Address - Country:US
Mailing Address - Phone:615-369-9897
Mailing Address - Fax:888-782-8545
Practice Address - Street 1:1422 KNIGHT DR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-6760
Practice Address - Country:US
Practice Address - Phone:615-369-9897
Practice Address - Fax:888-782-8545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3021251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ016682Medicaid