Basic Information
| Provider Information | |||||||||
| NPI: | 1568524759 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRONTIER HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ERWIN MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1167 SPRATLIN PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376159054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | ERWIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376501234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237431470 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMMONDS | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4234673600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | L-214-076-1410 | TN | N | Agencies | Case Management | 251S00000X | L-214-076-1410 | TN | N | Agencies | Community/Behavioral Health | 251S00000X | L000000015381 | TN | N | Agencies | Community/Behavioral Health | 261QR0405X | L000000015381 | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | L-214-076-1410 | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0801X | L000000015381 | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | 322 | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 251B00000X | L000000015381 | TN | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 3920247 | 05 | TN | MEDICAID | 49-4913-7 | 05 | VA | MEDICAID | SAME AS MEDICARE #S | 05 | TN | MEDICAID |