Healthcare Provider Details

I. General information

NPI: 1336912732
Provider Name (Legal Business Name): MIND RESTORATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/07/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 BROADWAY STE Y
ALBANY NY
12207-2922
US

IV. Provider business mailing address

418 BROADWAY STE Y
ALBANY NY
12207-2922
US

V. Phone/Fax

Practice location:
  • Phone: 833-294-6969
  • Fax:
Mailing address:
  • Phone: 833-294-6969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LATISHA MYRIE
Title or Position: CEO
Credential:
Phone: 833-294-6969