Evan Ganick
Individual provider Active NPI Adult Mental Health Clinic/Center · Elmwood, TN
NPI 1003562869 · NPPES record last updated Mar 1, 2022
Key facts
- NPI
- 1003562869
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Adult Mental Health Clinic/Center 261QM0850X
- License
- 115656 (NY)
- Practice address
- 89 Ouchonder Rd
Elmwood, TN 38560-4232 - Phone
- (615) 579-6241
- NPI assigned
- Mar 1, 2022
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 115656 | NY | MD | Adult Mental Health Clinic/Center |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Vet Care Foundation | Adult Mental Health | Current | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 115656 | NY | |
| Adult Mental Health Clinic/Center | 261QM0850X | 115656 | NY | Yes |
Addresses
Primary practice location
89 Ouchonder Rd
Elmwood, TN 38560-4232
Mailing address
89 Ouchonder Rd
Elmwood, TN 38560-4232
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| P-IND4MBYJ6QCTX-00 | Other | NY | NASW LIABILITY INSURANCE |
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| SOAP URL | simplepractice | Health Information Exchange (HIE) | |
| SOAP URL | evan@modernintimacy.com |
Other providers in Elmwood, TN
All providers in Elmwood, TN · Adult Mental Health Clinic/Center in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 1, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.