Provider Demographics
NPI:1063048668
Name:MIND AND BODY WELLNESS CLINIC
Entity type:Organization
Organization Name:MIND AND BODY WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MALADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-737-1992
Mailing Address - Street 1:1176 VICKERY LN STE 100
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0631
Mailing Address - Country:US
Mailing Address - Phone:901-737-1992
Mailing Address - Fax:901-309-8784
Practice Address - Street 1:1176 VICKERY LN STE 100
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0631
Practice Address - Country:US
Practice Address - Phone:901-737-1992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44725OtherLICENSE