1417285610 NPI number — MIND GUIDE, LCSW, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417285610 NPI number — MIND GUIDE, LCSW, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND GUIDE, LCSW, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417285610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 LAKEVILLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11576-2514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-748-0814
Provider Business Mailing Address Fax Number:
516-620-4567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11020 71ST RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375-4945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-748-0814
Provider Business Practice Location Address Fax Number:
516-620-4567
Provider Enumeration Date:
11/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROITGARTS
Authorized Official First Name:
IRENA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT AND PSYCHOTHERAPIST
Authorized Official Telephone Number:
917-748-0814

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  071633 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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