Provider Demographics
NPI:1265796072
Name:PEACE OF MIND THERAPY SERVICES
Entity type:Organization
Organization Name:PEACE OF MIND THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARTSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:423-444-3677
Mailing Address - Street 1:207 BOONE ST
Mailing Address - Street 2:SUITE 27
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5603
Mailing Address - Country:US
Mailing Address - Phone:423-444-3677
Mailing Address - Fax:423-244-0602
Practice Address - Street 1:207 BOONE ST
Practice Address - Street 2:SUITE 27
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5603
Practice Address - Country:US
Practice Address - Phone:423-444-3677
Practice Address - Fax:423-244-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN49021041C0700X
TN53911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
103I802362OtherMEDICARE PTAN