Healthcare Provider Details

I. General information

NPI: 1508359589
Provider Name (Legal Business Name): MINDFUL PATH PSYCHOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210 112TH ST OFC B
FOREST HILLS NY
11375-5467
US

IV. Provider business mailing address

7210 112TH ST OFC B
FOREST HILLS NY
11375-5467
US

V. Phone/Fax

Practice location:
  • Phone: 862-216-8398
  • Fax: 718-873-2089
Mailing address:
  • Phone: 862-216-8398
  • Fax: 718-873-2089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number021836
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number021836
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number021836
License Number StateNY

VIII. Authorized Official

Name: DR. JOSEPH F ATANASIO III
Title or Position: PRESIDENT
Credential: PSYD
Phone: 862-216-8398