Provider Demographics
NPI:1700575677
Name:OPTIMUM BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:OPTIMUM BEHAVIORAL SERVICES LLC
Other - Org Name:HOME OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MUTINTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHESTNUT
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:443-557-8519
Mailing Address - Street 1:6340 SECURITY BLVD STE B-56
Mailing Address - Street 2:
Mailing Address - City:WOODLAWN
Mailing Address - State:MD
Mailing Address - Zip Code:21207-5173
Mailing Address - Country:US
Mailing Address - Phone:443-557-8519
Mailing Address - Fax:
Practice Address - Street 1:5020 ROUTE 9W STE 103
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-7901
Practice Address - Country:US
Practice Address - Phone:443-557-8519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-05
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty