Healthcare Provider Details

I. General information

NPI: 1336745058
Provider Name (Legal Business Name): INTEGRATIVE WELLNESS NURSE PRACTITIONER IN PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 E 86TH ST STE 4
NEW YORK NY
10028-2175
US

IV. Provider business mailing address

169 MADISON AVE STE 38577
NEW YORK NY
10016-5101
US

V. Phone/Fax

Practice location:
  • Phone: 718-790-4511
  • Fax: 646-809-8707
Mailing address:
  • Phone: 718-790-4511
  • Fax: 646-809-8707

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: CLAUDIA MC BRIDE
Title or Position: EXECUTIVE ASSOCIATE
Credential:
Phone: 914-850-2593