1912434234 NPI number — MIND BODY SOUL - PSYCHOLOGY AND CONSULTING GROUP LLC

Table of content: (NPI 1912434234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912434234 NPI number — MIND BODY SOUL - PSYCHOLOGY AND CONSULTING GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND BODY SOUL - PSYCHOLOGY AND CONSULTING GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912434234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 DANBURY ROAD
Provider Second Line Business Mailing Address:
LOWER LEVEL, SUITE D6
Provider Business Mailing Address City Name:
RIDGEFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-494-8468
Provider Business Mailing Address Fax Number:
845-582-0764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 DANBURY ROAD
Provider Second Line Business Practice Location Address:
LOWER LEVEL, SUITE D6
Provider Business Practice Location Address City Name:
RIDGEFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06877-0687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-494-8468
Provider Business Practice Location Address Fax Number:
845-582-0764
Provider Enumeration Date:
05/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
203-494-8468

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2706 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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