Provider Demographics
NPI:1649752767
Name:AGELESS MIND NY INC
Entity Type:Organization
Organization Name:AGELESS MIND NY INC
Other - Org Name:AGELESS MIND NY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IZABELLE
Authorized Official - Middle Name:REYHANIAN
Authorized Official - Last Name:HAKIM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, EMPA
Authorized Official - Phone:516-726-0301
Mailing Address - Street 1:55 NORTHERN BLVD STE 406
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4058
Mailing Address - Country:US
Mailing Address - Phone:516-726-0301
Mailing Address - Fax:
Practice Address - Street 1:55 NORTHERN BLVD STE 406
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4058
Practice Address - Country:US
Practice Address - Phone:516-726-0301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078204-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty