Provider Demographics
NPI:1477233187
Name:MIND AND BODY WELLNESS
Entity type:Organization
Organization Name:MIND AND BODY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:631-404-6431
Mailing Address - Street 1:1300 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1339
Mailing Address - Country:US
Mailing Address - Phone:631-404-6431
Mailing Address - Fax:
Practice Address - Street 1:1300 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1339
Practice Address - Country:US
Practice Address - Phone:631-404-6431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty