Provider Demographics
NPI:1740045004
Name:MIND, BODY & SOUL PSYCHIATRY, P.A.
Entity type:Organization
Organization Name:MIND, BODY & SOUL PSYCHIATRY, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:SOFIA
Authorized Official - Last Name:GLACCUM-GAVAGNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-546-2707
Mailing Address - Street 1:900 SW 196TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1329
Mailing Address - Country:US
Mailing Address - Phone:954-546-2707
Mailing Address - Fax:954-820-5592
Practice Address - Street 1:900 SW 196TH AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1329
Practice Address - Country:US
Practice Address - Phone:954-546-2707
Practice Address - Fax:954-820-5592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty