Provider Demographics
NPI:1710929450
Name:MIND BODY WELLNESS PC
Entity Type:Organization
Organization Name:MIND BODY WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROPER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:214-763-1985
Mailing Address - Street 1:PO BOX 934068
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33093-4068
Mailing Address - Country:US
Mailing Address - Phone:954-366-2700
Mailing Address - Fax:954-366-2056
Practice Address - Street 1:17304 PRESTON RD STE 800
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5645
Practice Address - Country:US
Practice Address - Phone:972-849-8987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178166801Medicaid
TXDB9626Medicare PIN
TXDB9626 RAILROADMedicare PIN
TX00627WMedicare PIN
TX00627WMedicare ID - Type Unspecified
TX00626WMedicare PIN