Provider Demographics
NPI:1245052885
Name:MIND BRIDGE WELLNESS
Entity type:Organization
Organization Name:MIND BRIDGE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:347-300-5858
Mailing Address - Street 1:1102 GATES AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-4304
Mailing Address - Country:US
Mailing Address - Phone:347-300-5858
Mailing Address - Fax:
Practice Address - Street 1:445 PARK AVENUE FL 9
Practice Address - Street 2:90167
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:347-300-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)