Provider Demographics
NPI:1699063362
Name:MIND BODY RECOVERY CENTER, LLC
Entity type:Organization
Organization Name:MIND BODY RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:201-543-3935
Mailing Address - Street 1:12 N STATE RT 17
Mailing Address - Street 2:SUITE 313
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2644
Mailing Address - Country:US
Mailing Address - Phone:201-543-3935
Mailing Address - Fax:201-226-1141
Practice Address - Street 1:12 N STATE RT 17
Practice Address - Street 2:SUITE 313
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2644
Practice Address - Country:US
Practice Address - Phone:201-543-3935
Practice Address - Fax:201-226-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-15
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SCO5258800251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health