Healthcare Provider Details

I. General information

NPI: 1831028794
Provider Name (Legal Business Name): MIND BODY CONNECT NURSE PRACTITIONER IN PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 LORIMER ST STE D5055
BROOKLYN NY
11206-1030
US

IV. Provider business mailing address

442 LORIMER ST STE D5055
BROOKLYN NY
11206-1030
US

V. Phone/Fax

Practice location:
  • Phone: 646-718-6938
  • Fax: 929-990-2842
Mailing address:
  • Phone: 646-718-6938
  • Fax: 929-990-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TEZRA WHITE
Title or Position: PRESIDENT
Credential: PMHNP-BC, FNP-BC
Phone: 718-844-2017