=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144911603
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAS BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2023
-----------------------------------------------------
Last Update Date | 12/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 W FRANKLIN ST STE 201
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740-4863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-599-5177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 CEDAR REACH LN
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20720-5808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-599-5177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OF ENTITY
-----------------------------------------------------
Name | LINDA NKONGCHU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-599-5177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------