Provider Demographics
NPI:1487395968
Name:MIND OVER MATTER BEHAVIORAL SERVICES LLC
Entity type:Organization
Organization Name:MIND OVER MATTER BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:636-221-7686
Mailing Address - Street 1:304 N DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JACOB
Mailing Address - State:IL
Mailing Address - Zip Code:62281-1539
Mailing Address - Country:US
Mailing Address - Phone:636-221-7686
Mailing Address - Fax:
Practice Address - Street 1:304 N DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:SAINT JACOB
Practice Address - State:IL
Practice Address - Zip Code:62281-1539
Practice Address - Country:US
Practice Address - Phone:636-221-7686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty