Provider Demographics
NPI:1861027146
Name:HAGERSTOWN INTEGRATIVE MENTAL HEALTH
Entity Type:Organization
Organization Name:HAGERSTOWN INTEGRATIVE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, CRNP
Authorized Official - Phone:865-804-4067
Mailing Address - Street 1:14315 LUELLA PL
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-1186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1185 MOUNT AETNA RD STE 102
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6832
Practice Address - Country:US
Practice Address - Phone:865-804-4067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty