Provider Demographics
NPI:1205084118
Name:MIND BODY PROGRAM LLC
Entity type:Organization
Organization Name:MIND BODY PROGRAM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:GEBHARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-807-8934
Mailing Address - Street 1:15300 WATERTOWN PLANK RD #106
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2300
Mailing Address - Country:US
Mailing Address - Phone:414-807-8934
Mailing Address - Fax:
Practice Address - Street 1:15300 WATERTOWN PLANK RD STE 106
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2348
Practice Address - Country:US
Practice Address - Phone:414-807-8934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2028103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84062001Medicare PIN