Provider Demographics
NPI:1902536410
Name:MINDWELL PSYCHOLOGICAL ASSESSMENT, LLP
Entity type:Organization
Organization Name:MINDWELL PSYCHOLOGICAL ASSESSMENT, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:RAKOW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:607-260-3100
Mailing Address - Street 1:950 DANBY RD STE 202
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5714
Mailing Address - Country:US
Mailing Address - Phone:607-260-3100
Mailing Address - Fax:
Practice Address - Street 1:15 CORNELL RD STE 2
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1490
Practice Address - Country:US
Practice Address - Phone:607-260-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINDWELL CENTER, LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1992316400Medicaid