Provider Demographics
NPI:1033744404
Name:MONDAL, ROMAN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:MONDAL
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 47TH AVE STE 3100
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3050
Mailing Address - Country:US
Mailing Address - Phone:516-613-5750
Mailing Address - Fax:
Practice Address - Street 1:3100 47TH AVE STE 3100
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3050
Practice Address - Country:US
Practice Address - Phone:516-596-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403399363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health