=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780482257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASTERMIND COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 SHERWOOD PKWY STE 7
-----------------------------------------------------
City | MOUNTAINSIDE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07092-2525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-768-7039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 BURNSIDE AVE FL 2
-----------------------------------------------------
City | CRANFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07016-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-768-7039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. ZOEY KYRIACOU
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 908-768-7039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------