Provider Demographics
NPI:1578029377
Name:MIND BODY COUNSELING LLC
Entity Type:Organization
Organization Name:MIND BODY COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDISERRA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-373-2828
Mailing Address - Street 1:100 HUNTING HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4314
Mailing Address - Country:US
Mailing Address - Phone:860-373-2828
Mailing Address - Fax:
Practice Address - Street 1:352 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:CT
Practice Address - Zip Code:06422-1645
Practice Address - Country:US
Practice Address - Phone:860-373-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-16
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty