Provider Demographics
NPI:1962063073
Name:MOLDING YOUNG MINDS LLC
Entity type:Organization
Organization Name:MOLDING YOUNG MINDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILLANN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:917-592-2506
Mailing Address - Street 1:311 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-3306
Mailing Address - Country:US
Mailing Address - Phone:917-592-2506
Mailing Address - Fax:
Practice Address - Street 1:311 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-3306
Practice Address - Country:US
Practice Address - Phone:917-592-2506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency