1174110969 NPI number — THE MIND WELLNESS CONNECTION LCSW PLLC

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 1174110969 NPI number — THE MIND WELLNESS CONNECTION LCSW PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MIND WELLNESS CONNECTION LCSW PLLC
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:
1174110969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2005 PALMER AVE # 1182
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARCHMONT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10538-2437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
929-445-3346
Provider Business Mailing Address Fax Number:
914-833-1175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2005 PALMER AVE # 1182
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARCHMONT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10538-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
929-445-3346
Provider Business Practice Location Address Fax Number:
914-833-1175
Provider Enumeration Date:
12/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
FABRIS
Authorized Official First Name:
ANASTATIA
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
929-445-3346

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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