Provider Demographics
NPI:1992971675
Name:MINDBODY WELLNESS, LLC
Entity type:Organization
Organization Name:MINDBODY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILLIS-CENTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:417-440-0826
Mailing Address - Street 1:1407 S ELLIOTT AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-2103
Mailing Address - Country:US
Mailing Address - Phone:417-440-0826
Mailing Address - Fax:
Practice Address - Street 1:1407 S ELLIOTT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2103
Practice Address - Country:US
Practice Address - Phone:417-440-0826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008007986103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty