Provider Demographics
NPI:1215258991
Name:MIND & BODY BALANCE, LLC
Entity type:Organization
Organization Name:MIND & BODY BALANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-403-5149
Mailing Address - Street 1:4443 N RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3823
Mailing Address - Country:US
Mailing Address - Phone:773-403-5149
Mailing Address - Fax:
Practice Address - Street 1:1300 W BELMONT AVE STE 407
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3242
Practice Address - Country:US
Practice Address - Phone:773-403-5149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490106621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty