Provider Demographics
NPI:1508540956
Name:MIND AND BODY WELLNESS, LLC.
Entity type:Organization
Organization Name:MIND AND BODY WELLNESS, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-409-6049
Mailing Address - Street 1:PO BOX 6632
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-6632
Mailing Address - Country:US
Mailing Address - Phone:479-409-6049
Mailing Address - Fax:479-600-5051
Practice Address - Street 1:720 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4738
Practice Address - Country:US
Practice Address - Phone:479-910-3169
Practice Address - Fax:479-600-5051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-14
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR322060002Medicaid