Provider Demographics
NPI:1528643459
Name:MINDFUL MOTION THERAPY, LLC.
Entity type:Organization
Organization Name:MINDFUL MOTION THERAPY, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:DOT, MOT
Authorized Official - Phone:860-881-5755
Mailing Address - Street 1:6 FERNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2902
Mailing Address - Country:US
Mailing Address - Phone:860-881-5755
Mailing Address - Fax:
Practice Address - Street 1:20 AVON MEADOW LN STE 210
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3731
Practice Address - Country:US
Practice Address - Phone:860-881-5755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251E00000XAgenciesHome Health