Healthcare Provider Details

I. General information

NPI: 1104325695
Provider Name (Legal Business Name): MARY MITCHELL HADDAD PMHNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E 43RD ST RM 1305
NEW YORK NY
10017-4779
US

IV. Provider business mailing address

960 GREEN CIR
ORANGE CT
06477-1736
US

V. Phone/Fax

Practice location:
  • Phone: 203-952-7571
  • Fax: 212-642-5111
Mailing address:
  • Phone: 203-952-7571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberF402319-1
License Number StateNY

VIII. Authorized Official

Name: MS. MARY MITCHELL HADDAD
Title or Position: PMHNP
Credential: RN, MSN, PMHNP
Phone: 203-952-7571