Healthcare Provider Details

I. General information

NPI: 1649707555
Provider Name (Legal Business Name): NOURISH YOUR MIND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 STATE ROUTE 17M STE 4
MONROE NY
10950-3444
US

IV. Provider business mailing address

360 STATE ROUTE 17M STE 4
MONROE NY
10950-3444
US

V. Phone/Fax

Practice location:
  • Phone: 845-547-0479
  • Fax: 845-547-0479
Mailing address:
  • Phone: 845-547-0479
  • Fax: 845-547-0479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number085591
License Number StateNY

VIII. Authorized Official

Name: JESSICA C SULLIVAN
Title or Position: OWNER
Credential: LCSW
Phone: 845-547-0479