Provider Demographics
NPI:1154954634
Name:MIND BODY & SOUL BEHAVIORAL HEALTH AND WELLNESS LLC
Entity type:Organization
Organization Name:MIND BODY & SOUL BEHAVIORAL HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHUKAIRO
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LISW-CP, LCAS
Authorized Official - Phone:980-309-8508
Mailing Address - Street 1:1365 EBENEZER RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2336
Mailing Address - Country:US
Mailing Address - Phone:803-708-7556
Mailing Address - Fax:803-708-7801
Practice Address - Street 1:1365 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2336
Practice Address - Country:US
Practice Address - Phone:803-708-7556
Practice Address - Fax:803-708-7801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health