Provider Demographics
NPI:1144732074
Name:ALTUM PSYCHIATRIC SERVICES, PLLC
Entity type:Organization
Organization Name:ALTUM PSYCHIATRIC SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CYMANDE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAXTER-ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:352-226-3803
Mailing Address - Street 1:1 BRIDGE ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-1623
Mailing Address - Country:US
Mailing Address - Phone:352-226-3803
Mailing Address - Fax:
Practice Address - Street 1:1 BRIDGE ST STE 210
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1623
Practice Address - Country:US
Practice Address - Phone:352-226-3803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-01
Last Update Date:2017-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH07475223363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306591000Medicaid