Provider Demographics
NPI:1306019468
Name:STONEGATE BEHAVIORAL HEALTH PC
Entity Type:Organization
Organization Name:STONEGATE BEHAVIORAL HEALTH PC
Other - Org Name:ANDRE PUNCH
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:EASTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-300-1590
Mailing Address - Street 1:4686 BRISTOL TRACE TRL
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-6947
Mailing Address - Country:US
Mailing Address - Phone:817-300-1590
Mailing Address - Fax:
Practice Address - Street 1:4686 BRISTOL TRACE TRL
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-6947
Practice Address - Country:US
Practice Address - Phone:817-300-1590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty