Basic Information
| Provider Information | |||||||||
| NPI: | 1063728251 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIND, BODY & SOUL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 BROADFIELD BLVD, | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770845162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819067134 | ||||||||
| FaxNumber: | 2816121160 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 BROADFIELD BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770845162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819067134 | ||||||||
| FaxNumber: | 2816121160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BIRTS | ||||||||
| AuthorizedOfficialFirstName: | TAMEKA | ||||||||
| AuthorizedOfficialMiddleName: | NICHOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7708730087 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 251B00000X | N | Agencies | Case Management | 251S00000X | N | Agencies | Community/Behavioral Health | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.