Provider Demographics
NPI:1811422611
Name:MIND, BODY & SPIRIT COUNSELING LLC
Entity Type:Organization
Organization Name:MIND, BODY & SPIRIT COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORRI
Authorized Official - Middle Name:K
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:CMHC
Authorized Official - Phone:801-520-3490
Mailing Address - Street 1:2180 E 4500 S STE 125
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4021
Mailing Address - Country:US
Mailing Address - Phone:801-520-3490
Mailing Address - Fax:
Practice Address - Street 1:2180 E 4500 S STE 125
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4021
Practice Address - Country:US
Practice Address - Phone:801-520-3490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-29
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty