=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346969540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND GARDEN MENTAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2022
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 1ST ST STE 1800
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02142-1292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-430-4309
-----------------------------------------------------
Fax | 781-205-1614
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 FORTUNE BLVD # 1009
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01757-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-242-6010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAROLYNE MBURU- GERENA
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 413-242-6010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------