MEDICARE: MINDFUL NP IN PSYCHIATRY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1558178764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL NP IN PSYCHIATRY PLLC

Provider Business Mailing Address
First Line	:	5 LAURA RD
Second Line	:
City	:	MONROE
State	:	NY
Zip	:	10950-5206
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 LAURA RD
Second Line	:
City	:	MONROE
State	:	NY
Zip	:	10950-5206
Country	:	US
Telephone Number	:	845-659-4508
Fax Number	:	845-654-8645

Authorized Official
Title or Position	:	PMHNP-C
Name	:	CASSANDRA FORTUNE
Credential	:
Telephone Number	:	845-659-4508

Provider Enumeration Date	:	12/12/2024
Last Update Date	:	01/14/2026

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