Healthcare Provider Details

I. General information

NPI: 1144951393
Provider Name (Legal Business Name): MINDFUL LIVING PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 NORTHRIDGE ST
PATCHOGUE NY
11772-2822
US

IV. Provider business mailing address

380 E SUNRISE HWY # 1028
PATCHOGUE NY
11772-1906
US

V. Phone/Fax

Practice location:
  • Phone: 631-517-3251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JOHANNA SANGEMINO
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 631-517-3251