Provider Demographics
NPI:1750862017
Name:MIND BODY WELLNESS GROUP LLC
Entity Type:Organization
Organization Name:MIND BODY WELLNESS GROUP LLC
Other - Org Name:MIND BODY WELLNESS GROUP LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:STONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:727-310-5520
Mailing Address - Street 1:735 ARLINGTON AVE N STE 205
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3653
Mailing Address - Country:US
Mailing Address - Phone:727-310-5520
Mailing Address - Fax:
Practice Address - Street 1:735 ARLINGTON AVE N STE 205
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3653
Practice Address - Country:US
Practice Address - Phone:727-310-5520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW14906101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1629433636OtherNPI