Provider Demographics
NPI:1841441284
Name:CENTER FOR MIND BRAIN & BEHAVIORAL MEDICINE,INC
Entity type:Organization
Organization Name:CENTER FOR MIND BRAIN & BEHAVIORAL MEDICINE,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHISHUKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHOLTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-453-9085
Mailing Address - Street 1:4825 HIGBEE AVE NW
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2567
Mailing Address - Country:US
Mailing Address - Phone:330-453-9085
Mailing Address - Fax:330-453-9089
Practice Address - Street 1:4825 HIGBEE AVE NW
Practice Address - Street 2:SUITE 102
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2567
Practice Address - Country:US
Practice Address - Phone:330-453-9085
Practice Address - Fax:330-453-9089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079074M174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty