Provider Demographics
NPI:1104699974
Name:JACQUELINE SHALL-MCCUMISKEY, PSY.D. MINDFUL PRACTICE
Entity type:Organization
Organization Name:JACQUELINE SHALL-MCCUMISKEY, PSY.D. MINDFUL PRACTICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALL-MCCUMISKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-479-8068
Mailing Address - Street 1:1675 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2317
Practice Address - Country:US
Practice Address - Phone:646-479-8068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1104699974
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty