Provider Demographics
NPI:1205239480
Name:MINDHEALTH PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:MINDHEALTH PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:LAUREN
Authorized Official - Last Name:HAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:845-784-7862
Mailing Address - Street 1:3669 MAIN ST STE 5
Mailing Address - Street 2:P.O. BOX 894
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-5613
Mailing Address - Country:US
Mailing Address - Phone:845-784-7862
Mailing Address - Fax:
Practice Address - Street 1:3669 MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5613
Practice Address - Country:US
Practice Address - Phone:845-784-7862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty