Provider Demographics
NPI:1780382937
Name:BODHI MIND AND BODY WELLNESS CENTER
Entity type:Organization
Organization Name:BODHI MIND AND BODY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:908-910-5414
Mailing Address - Street 1:146 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT MONMOUTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07758-1341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1715 UNION AVE FL 2
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-2443
Practice Address - Country:US
Practice Address - Phone:908-910-5414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty