=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083411896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEA GLASS BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2025
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1147 S. SALISBURY BLVD SUITE 8 281
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-6865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-979-8902
-----------------------------------------------------
Fax | 443-313-6948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1147 S. SALISBURY BLVD SUITE 8 281
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-6865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-979-8902
-----------------------------------------------------
Fax | 443-313-6948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PROVIDER
-----------------------------------------------------
Name | JULIE ANNE KINHART
-----------------------------------------------------
Credential | CRNP-PMH
-----------------------------------------------------
Telephone | 443-366-4385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------