Healthcare Provider Details

I. General information

NPI: 1255172631
Provider Name (Legal Business Name): THE IMIND FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2024
Last Update Date: 06/01/2024
Certification Date: 06/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 NW CENTRAL PARK PLZ STE 112
PORT SAINT LUCIE FL
34986-2482
US

IV. Provider business mailing address

160 NW CENTRAL PARK PLZ STE 104
PORT SAINT LUCIE FL
34986-1825
US

V. Phone/Fax

Practice location:
  • Phone: 772-617-6373
  • Fax: 844-440-1724
Mailing address:
  • Phone: 772-617-6373
  • Fax: 844-440-1724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN KALEL BAKSH
Title or Position: CEO
Credential: LMHC, MCAP
Phone: 772-617-6373