Provider Demographics
NPI:1174110969
Name:THE MIND WELLNESS CONNECTION LCSW PLLC
Entity type:Organization
Organization Name:THE MIND WELLNESS CONNECTION LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANASTATIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FABRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:929-445-3346
Mailing Address - Street 1:2005 PALMER AVE # 1182
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-2437
Mailing Address - Country:US
Mailing Address - Phone:929-445-3346
Mailing Address - Fax:914-833-1175
Practice Address - Street 1:2005 PALMER AVE # 1182
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-2437
Practice Address - Country:US
Practice Address - Phone:929-445-3346
Practice Address - Fax:914-833-1175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health