Healthcare Provider Details

I. General information

NPI: 1023844909
Provider Name (Legal Business Name): GUMTREE MENTAL HEALTH & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 FULLERTON RD STE B
SWANSEA IL
62226-2901
US

IV. Provider business mailing address

405 N LINCOLN AVE
O FALLON IL
62269-1322
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-0006
  • Fax:
Mailing address:
  • Phone: 813-838-2707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KYRIA A BUCHANAN
Title or Position: NURSE PRACTITIONER
Credential: PMHNP-BC, APRN
Phone: 813-838-2707