=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932706413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKLYN HEALTHY MIND 360- NURSE PRACTITIONER IN PSYCHIATRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2020
-----------------------------------------------------
Last Update Date | 10/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 COURT ST STE 409
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11242-1134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-450-1294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 COURT ST STE 409
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11242-1134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-450-1294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | KELLIE CAREY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-729-8606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------