Healthcare Provider Details

I. General information

NPI: 1689591265
Provider Name (Legal Business Name): OPEN MIND MENTAL HEALTH COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 MANOR RD FL 1
STATEN ISLAND NY
10314-2958
US

IV. Provider business mailing address

65 CORONA AVE
STATEN ISLAND NY
10306-1150
US

V. Phone/Fax

Practice location:
  • Phone: 718-873-4835
  • Fax:
Mailing address:
  • Phone: 718-873-4835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER YAEL SAMUEL
Title or Position: MENTAL HEALTH COUNSELOR
Credential: LMHC
Phone: 718-873-4835