=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134938574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL PSYCHOLOGICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2024
-----------------------------------------------------
Last Update Date | 12/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 353 LEXINGTON AVE THERAPEUTIC ALLIANCE SUITES FL 2, OFFICE 1
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-0941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-623-7185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 353 LEXINGTON AVE THERAPEUTIC ALLIANCE SUITES FL 2, OFFICE 1
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-0941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MELISSA JERMANN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 631-623-7185
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------