Provider Demographics
NPI:1972063691
Name:MIND BODY OT LLC
Entity type:Organization
Organization Name:MIND BODY OT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:920-763-3534
Mailing Address - Street 1:W9018 COUNTY RD S
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-9680
Mailing Address - Country:US
Mailing Address - Phone:920-763-3534
Mailing Address - Fax:
Practice Address - Street 1:201 GATEWAY DR.
Practice Address - Street 2:STE 300
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-9176
Practice Address - Country:US
Practice Address - Phone:920-763-3534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-20
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation