Healthcare Provider Details

I. General information

NPI: 1689204307
Provider Name (Legal Business Name): KRISTEN NASH BUMGARNER MA, LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 GATEWAY BLVD STE C
MOORESVILLE NC
28117-5544
US

IV. Provider business mailing address

122 GATEWAY BLVD STE C
MOORESVILLE NC
28117-5544
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-3637
  • Fax: 704-200-9829
Mailing address:
  • Phone: 704-360-3637
  • Fax: 704-200-9829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15286
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: