Provider Demographics
NPI:1285079137
Name:TREE OF LIFE BEHAVIORAL HEALTH SERVICES PSYCHIATRIC NP, PC
Entity type:Organization
Organization Name:TREE OF LIFE BEHAVIORAL HEALTH SERVICES PSYCHIATRIC NP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:JEANNETTE
Authorized Official - Last Name:NANS
Authorized Official - Suffix:
Authorized Official - Credentials:PNP FPMHNP
Authorized Official - Phone:315-286-0127
Mailing Address - Street 1:215 WASHINGTON ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3343
Mailing Address - Country:US
Mailing Address - Phone:315-286-0127
Mailing Address - Fax:
Practice Address - Street 1:215 WASHINGTON ST
Practice Address - Street 2:SUITE 221
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3329
Practice Address - Country:US
Practice Address - Phone:315-286-0127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7905039261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03410015Medicaid