Provider Demographics
NPI:1598391229
Name:MIND AND BODY WELLNESS LLC
Entity Type:Organization
Organization Name:MIND AND BODY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:630-546-2465
Mailing Address - Street 1:6825 WHITE EGRET CT
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3973
Mailing Address - Country:US
Mailing Address - Phone:630-546-2465
Mailing Address - Fax:
Practice Address - Street 1:6825 WHITE EGRET CT
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3973
Practice Address - Country:US
Practice Address - Phone:630-546-2465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty