=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215759204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARVEST MIND NP IN PSYCHIATRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2024
-----------------------------------------------------
Last Update Date | 08/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 RELLA BOULEVARD SUITE 207-137
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-991-7285
-----------------------------------------------------
Fax | 866-487-9572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 RELLA BOULEVARD SUITE 207-137
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-991-7285
-----------------------------------------------------
Fax | 866-487-9572
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCH NURSE PRACTITIONER, OWNER
-----------------------------------------------------
Name | SAMANTHA VASSOR
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 646-991-7285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------