Basic Information
Provider Information | |||||||||
NPI: | 1053475558 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRONTIER HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HANCOCK COUNTY MENTAL HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9054 | ||||||||
Address2: |   | ||||||||
City: | GRAY | ||||||||
State: | TN | ||||||||
PostalCode: | 376159054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234673600 | ||||||||
FaxNumber: | 4234673644 | ||||||||
Practice Location | |||||||||
Address1: | 210 RIVER ROAD | ||||||||
Address2: |   | ||||||||
City: | SNEEDVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378693904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237332216 | ||||||||
FaxNumber: | 4237332450 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2006 | ||||||||
LastUpdateDate: | 01/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAMMONDS | ||||||||
AuthorizedOfficialFirstName: | KRISTIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 4234673600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: | 01/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | L 214-076-1415 | TN | N |   | Agencies | Case Management |   | 251S00000X | L 214-076-1415 | TN | N |   | Agencies | Community/Behavioral Health |   | 261QR0405X | 372 | TN | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | L 214-076-1415 | TN | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | SAME AS MEDICARE #S | 05 | TN |   | MEDICAID |