Provider Demographics
NPI:1912434234
Name:MIND BODY SOUL - PSYCHOLOGY AND CONSULTING GROUP LLC
Entity Type:Organization
Organization Name:MIND BODY SOUL - PSYCHOLOGY AND CONSULTING GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:203-494-8468
Mailing Address - Street 1:109 DANBURY ROAD
Mailing Address - Street 2:LOWER LEVEL, SUITE D6
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877
Mailing Address - Country:US
Mailing Address - Phone:203-494-8468
Mailing Address - Fax:845-582-0764
Practice Address - Street 1:109 DANBURY ROAD
Practice Address - Street 2:LOWER LEVEL, SUITE D6
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-0687
Practice Address - Country:US
Practice Address - Phone:203-494-8468
Practice Address - Fax:845-582-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2706103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty