=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376260323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDCARE PLUS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2022
-----------------------------------------------------
Last Update Date | 10/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 992 CLIFTON AVE FL 1
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-249-1266
-----------------------------------------------------
Fax | 862-249-1267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 992 CLIFTON AVE FL 1
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-249-1266
-----------------------------------------------------
Fax | 862-249-1267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | REHAN MALIK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 862-249-1266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------