Healthcare Provider Details

I. General information

NPI: 1962296806
Provider Name (Legal Business Name): MIND BLOOM PSYCHIATRY HEALTH WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 03/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E SUNRISE HWY STE 500
VALLEY STREAM NY
11581-1233
US

IV. Provider business mailing address

70 E SUNRISE HWY STE 500
VALLEY STREAM NY
11581-1233
US

V. Phone/Fax

Practice location:
  • Phone: 516-531-3519
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1548658545
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI

VIII. Authorized Official

Name: MAANVI KUMAR
Title or Position: OWNER
Credential:
Phone: 516-754-7969