=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275261448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHYMINDSP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2022
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 5TH AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10175-0003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-653-5120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 CEDAR TER
-----------------------------------------------------
City | HILTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14468-1445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-991-5212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | SUSAN HART
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 571-991-5212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------