Provider Demographics
NPI:1558183723
Name:MIND/BODY INSTITUTE, LLC
Entity type:Organization
Organization Name:MIND/BODY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-S
Authorized Official - Phone:330-510-5221
Mailing Address - Street 1:3511 CENTER RD STE J
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3693
Mailing Address - Country:US
Mailing Address - Phone:330-510-5221
Mailing Address - Fax:330-510-5228
Practice Address - Street 1:3511 CENTER RD STE J
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3693
Practice Address - Country:US
Practice Address - Phone:330-510-5221
Practice Address - Fax:330-510-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-29
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health