Provider Demographics
NPI:1588072763
Name:BODY MIND SOUL LLC
Entity type:Organization
Organization Name:BODY MIND SOUL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JORGENSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:269-615-8639
Mailing Address - Street 1:P.O. BOX 20056
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49019
Mailing Address - Country:US
Mailing Address - Phone:269-615-8639
Mailing Address - Fax:
Practice Address - Street 1:5985 WEST MAIN STREET
Practice Address - Street 2:814
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009
Practice Address - Country:US
Practice Address - Phone:269-615-8639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15383511501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty