Provider Demographics
NPI:1508580937
Name:GO MINDFUL PRACTICE, LLC
Entity Type:Organization
Organization Name:GO MINDFUL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALL-MCCUMISKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:646-479-8068
Mailing Address - Street 1:20 HAVEN ESPLANADE ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2717
Mailing Address - Country:US
Mailing Address - Phone:646-479-8068
Mailing Address - Fax:
Practice Address - Street 1:525 ROUTE 73 N STE 104
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3422
Practice Address - Country:US
Practice Address - Phone:646-479-8068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty