Provider Demographics
NPI:1255733853
Name:BODY MIND SPIRIT IOP INC
Entity type:Organization
Organization Name:BODY MIND SPIRIT IOP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-247-7377
Mailing Address - Street 1:665 CAMINO DE LOS MARES STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2840
Mailing Address - Country:US
Mailing Address - Phone:949-248-7377
Mailing Address - Fax:866-805-2796
Practice Address - Street 1:665 CAMINO DE LOS MARES STE 104
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673
Practice Address - Country:US
Practice Address - Phone:949-248-7377
Practice Address - Fax:866-805-2796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9840103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty