Provider Demographics
NPI:1396234878
Name:MIMNAUGH, CAITLIN
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:MIMNAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-6327
Mailing Address - Country:US
Mailing Address - Phone:516-458-9143
Mailing Address - Fax:
Practice Address - Street 1:50 W HAWTHORNE AVE FL 2
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6220
Practice Address - Country:US
Practice Address - Phone:516-569-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health