Provider Demographics
NPI:1174367825
Name:TWIN RIVERS MENTAL HEALTH
Entity type:Organization
Organization Name:TWIN RIVERS MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEI
Authorized Official - Middle Name:
Authorized Official - Last Name:FALLER
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, FNP-BC
Authorized Official - Phone:801-362-8764
Mailing Address - Street 1:8204 199TH RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-7747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8204 199TH RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-7747
Practice Address - Country:US
Practice Address - Phone:801-362-8764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty