Provider Demographics
NPI:1730671769
Name:MIND, BODY, AND SOUL THERAPY LLC
Entity Type:Organization
Organization Name:MIND, BODY, AND SOUL THERAPY LLC
Other - Org Name:MIND, BODY, AND SOUL THERAPY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYNISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:510-473-6062
Mailing Address - Street 1:PO BOX 17
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-0017
Mailing Address - Country:US
Mailing Address - Phone:510-473-6062
Mailing Address - Fax:
Practice Address - Street 1:2940 SUMMIT ST STE 2E
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3416
Practice Address - Country:US
Practice Address - Phone:510-473-6062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80925261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health