Provider Demographics
NPI:1730557018
Name:MINDCARE AGENCY PC
Entity type:Organization
Organization Name:MINDCARE AGENCY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:FARUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-271-7136
Mailing Address - Street 1:125 LIBERTY ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1114
Mailing Address - Country:US
Mailing Address - Phone:413-271-7136
Mailing Address - Fax:413-271-7137
Practice Address - Street 1:125 LIBERTY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1114
Practice Address - Country:US
Practice Address - Phone:413-271-7136
Practice Address - Fax:413-271-7137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 261QR0405X
MA2236742084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA223674OtherSTATE LICENSE NUMBER
MAMX9324Medicare PIN