Provider Demographics
NPI:1487301891
Name:MIND BODY INTEGRATED THERAPY, LLC
Entity type:Organization
Organization Name:MIND BODY INTEGRATED THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-840-5106
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-0542
Mailing Address - Country:US
Mailing Address - Phone:217-840-5106
Mailing Address - Fax:
Practice Address - Street 1:121 N STATE ST STE 2
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1677
Practice Address - Country:US
Practice Address - Phone:217-840-5106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-05
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty