Basic Information
| Provider Information | |||||||||
| NPI: | 1811659584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIND AND BODY INTEGRATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PENROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812409312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193718791 | ||||||||
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| Practice Location | |||||||||
| Address1: | 831 ROYAL GORGE BLVD STE 217 | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812126709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193718791 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2021 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | LIEBLI | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7193718791 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APN | ||||||||
| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.