Provider Demographics
NPI:1952987034
Name:BODY AND MINDFULLY HEALTHY, LLC
Entity Type:Organization
Organization Name:BODY AND MINDFULLY HEALTHY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:SUE ANN
Authorized Official - Last Name:PEDDY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:276-293-1235
Mailing Address - Street 1:PO BOX 1141
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-1141
Mailing Address - Country:US
Mailing Address - Phone:276-293-1235
Mailing Address - Fax:540-613-1831
Practice Address - Street 1:210 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-3806
Practice Address - Country:US
Practice Address - Phone:276-293-1235
Practice Address - Fax:540-613-1831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-20
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1538559588Medicaid