Provider Demographics
NPI:1366271512
Name:BRAIN BODY SOUL THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:BRAIN BODY SOUL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CARSON
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:918-236-0833
Mailing Address - Street 1:2834 E 90TH ST UNIT 1806
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-3377
Mailing Address - Country:US
Mailing Address - Phone:734-646-4354
Mailing Address - Fax:
Practice Address - Street 1:2488 E 81ST ST STE 4821
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4290
Practice Address - Country:US
Practice Address - Phone:918-236-0833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-27
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200946240BMedicaid