Provider Demographics
NPI:1578974143
Name:MIND BODY PROFESSIONAL CENTER
Entity Type:Organization
Organization Name:MIND BODY PROFESSIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BEUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:253-278-9292
Mailing Address - Street 1:PO BOX 1331
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0243
Mailing Address - Country:US
Mailing Address - Phone:253-278-9292
Mailing Address - Fax:253-604-6237
Practice Address - Street 1:15406 MERIDIAN E STE 103
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-9504
Practice Address - Country:US
Practice Address - Phone:253-278-9292
Practice Address - Fax:253-604-6237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60318110103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty