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General NPI Number Information
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NPI Number | 1649752767
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Entity Type | Organization
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Legal Business Name | AGELESS MIND NY INC
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Dates
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Enumeration Date | 09/05/2018
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Last Update Date | 01/10/2019
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Provider Practice Location Address
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Address Line | 55 NORTHERN BLVD STE 406
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City | GREAT NECK
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State | NY
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Zip | 11021-4058
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Country | US
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Telephone | 516-726-0301
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Fax |
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Provider Business Mailing Address
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Address Line | 55 NORTHERN BLVD STE 406
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City | GREAT NECK
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State | NY
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Zip | 11021-4058
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Country | US
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Telephone | 516-726-0301
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | IZABELLE REYHANIAN HAKIM
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Credential | LCSW, EMPA
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Telephone | 516-726-0301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 078204-1
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License Number State | NY
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