Healthcare Provider Details

I. General information

NPI: 1003551722
Provider Name (Legal Business Name): MIND PATH MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 05/13/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S SERVICE RD STE 101
ROSLYN HEIGHTS NY
11577-2133
US

IV. Provider business mailing address

81 WOODLAKE DR W
WOODBURY NY
11797-2305
US

V. Phone/Fax

Practice location:
  • Phone: 516-340-0340
  • Fax: 858-769-1571
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. SAAD KHAN
Title or Position: MANAGER
Credential: DO
Phone: 515-340-0340