Provider Demographics
NPI:1295519213
Name:MIND BODY CONNECTIONS LLC
Entity type:Organization
Organization Name:MIND BODY CONNECTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUPAL
Authorized Official - Suffix:
Authorized Official - Credentials:DNP-FNP, QMHP, PMHNP
Authorized Official - Phone:605-431-3388
Mailing Address - Street 1:8000 BLACK HAWK RD STE 4
Mailing Address - Street 2:
Mailing Address - City:BLACK HAWK
Mailing Address - State:SD
Mailing Address - Zip Code:57718-3315
Mailing Address - Country:US
Mailing Address - Phone:605-431-3388
Mailing Address - Fax:
Practice Address - Street 1:8000 BLACK HAWK RD STE 4
Practice Address - Street 2:
Practice Address - City:BLACK HAWK
Practice Address - State:SD
Practice Address - Zip Code:57718-3315
Practice Address - Country:US
Practice Address - Phone:605-431-3388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-21
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty