Provider Demographics
NPI:1629214358
Name:PRIZMS CENTER FOR MINDBODY INTEGRATION LLC
Entity Type:Organization
Organization Name:PRIZMS CENTER FOR MINDBODY INTEGRATION LLC
Other - Org Name:PRIZMS COUNSELING AND CONSULTING SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:336-761-5071
Mailing Address - Street 1:PO BOX 20323
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27120-0323
Mailing Address - Country:US
Mailing Address - Phone:336-761-5071
Mailing Address - Fax:336-761-5071
Practice Address - Street 1:115 N POPLAR ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3741
Practice Address - Country:US
Practice Address - Phone:336-761-5071
Practice Address - Fax:336-761-5071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2490101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty