Basic Information
| Provider Information | |||||||||
| NPI: | 1730557018 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINDCARE AGENCY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 LIBERTY ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011031114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132717136 | ||||||||
| FaxNumber: | 4132717137 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 LIBERTY ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011031114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132717136 | ||||||||
| FaxNumber: | 4132717137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2015 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | FARUK | ||||||||
| AuthorizedOfficialFirstName: | OMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4132717136 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 2084A0401X | 223674 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 223674 | 01 | MA | STATE LICENSE NUMBER | OTHER |