1093088502 NPI number — WINGSPAN PSYCHIATRIC, LLC

Table of content: VANESSA MEHTA (NPI 1912258666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093088502 NPI number — WINGSPAN PSYCHIATRIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINGSPAN PSYCHIATRIC, LLC
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:
FRANCIS HAYDEN, M.D.
Provider Other Organization Name Type Code:
4
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:
1093088502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 ELLWOOD AVE APT 4A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10552-3428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-413-1553
Provider Business Mailing Address Fax Number:
917-791-8239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 S COLUMBUS AVE FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10553-1337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-413-1553
Provider Business Practice Location Address Fax Number:
978-701-6001
Provider Enumeration Date:
02/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HAYDEN
Authorized Official First Name:
FRANCIS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
914-413-1553

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  189845 , 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)

  • Identifier: 01550791 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03438319 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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