=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992465157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INCLUSIVE MENTAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2021
-----------------------------------------------------
Last Update Date | 12/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 CO OP CITY BLVD APT 14D
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10475-1634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-697-3037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 CO OP CITY BLVD APT 14D
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10475-1634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-697-3037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | VINESSA MAXWELL
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 347-697-3037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------