Healthcare Provider Details

I. General information

NPI: 1881225688
Provider Name (Legal Business Name): JOURNEY 2 SERENITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MAIN ST STE 213
NYACK NY
10960-3109
US

IV. Provider business mailing address

99 MAIN ST STE 213
NYACK NY
10960-3109
US

V. Phone/Fax

Practice location:
  • Phone: 917-309-9184
  • Fax: 845-267-0030
Mailing address:
  • Phone: 917-309-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARMEN NIEVES-PACHECO
Title or Position: OWNER
Credential: CSW
Phone: 917-309-9184