Provider Demographics
NPI:1750128948
Name:HOME BODY HOLISTIC STUDIO LLC
Entity type:Organization
Organization Name:HOME BODY HOLISTIC STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:620-778-0513
Mailing Address - Street 1:19 E MOUNTAIN ST STE 33
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-6067
Mailing Address - Country:US
Mailing Address - Phone:479-530-6678
Mailing Address - Fax:
Practice Address - Street 1:19 E MOUNTAIN ST STE 33
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-6067
Practice Address - Country:US
Practice Address - Phone:479-530-6678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-13
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty