Provider Demographics
NPI:1699593483
Name:INTEGRATIVE MIND BODY PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:INTEGRATIVE MIND BODY PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUZA-HAMRICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-293-3039
Mailing Address - Street 1:8114 SW POKEGAMA DR
Mailing Address - Street 2:
Mailing Address - City:POWELL BUTTE
Mailing Address - State:OR
Mailing Address - Zip Code:97753-1564
Mailing Address - Country:US
Mailing Address - Phone:541-293-3039
Mailing Address - Fax:
Practice Address - Street 1:818 SW FOREST AVE STE B
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2737
Practice Address - Country:US
Practice Address - Phone:541-293-3039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health