Provider Demographics
NPI:1770105736
Name:MIND BODY MOTHERHOOD LLC
Entity type:Organization
Organization Name:MIND BODY MOTHERHOOD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NILSSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-357-1734
Mailing Address - Street 1:130 RICHARDSON DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-2124
Mailing Address - Country:US
Mailing Address - Phone:860-357-1734
Mailing Address - Fax:
Practice Address - Street 1:649 AMITY RD STE 103
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:CT
Practice Address - Zip Code:06524-3091
Practice Address - Country:US
Practice Address - Phone:860-357-1734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty