Provider Demographics
NPI:1295990513
Name:MIND BODY MEDICAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:MIND BODY MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:KERTIS
Authorized Official - Last Name:FRONK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-373-9990
Mailing Address - Street 1:110 ASH ST
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-1928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:824 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2508
Practice Address - Country:US
Practice Address - Phone:781-373-9990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPN97698101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO9691Medicare UPIN