Provider Demographics
NPI:1366062903
Name:EAGLE RIVER BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:EAGLE RIVER BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ZAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:907-726-0378
Mailing Address - Street 1:PO BOX 770870
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-0870
Mailing Address - Country:US
Mailing Address - Phone:907-290-7033
Mailing Address - Fax:206-726-0374
Practice Address - Street 1:12812 OLD GLENN HWY STE C4
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7002
Practice Address - Country:US
Practice Address - Phone:907-726-0378
Practice Address - Fax:907-726-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK240808Medicaid