Healthcare Provider Details

I. General information

NPI: 1013840289
Provider Name (Legal Business Name): MINDFUL WELLNESS NURSE PRACTITIONER IN PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 THRUSH LN
LEVITTOWN NY
11756-3211
US

IV. Provider business mailing address

14 THRUSH LN
LEVITTOWN NY
11756-3211
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-8407
  • Fax:
Mailing address:
  • Phone: 631-475-8407
  • Fax:

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: SYED TAHIR
Title or Position: OWNER
Credential: NP
Phone: 646-620-1010