=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306653902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND AT PEACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2024
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10216 65TH RD
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-1741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-208-5487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10216 65TH RD
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-1741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-208-5487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | OLGA MURATOV
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 718-208-5487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------