1023900651 NPI number — CENTERSTONE OF TENNESSEE, INC.

Table of content: STEPHANIE ROSE MODRAK MS (NPI 1427641208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023900651 NPI number — CENTERSTONE OF TENNESSEE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTERSTONE OF TENNESSEE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023900651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1960 KIMBALL AVE FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANHATTAN
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66502-3391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-463-6505
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1960 KIMBALL AVE FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANHATTAN
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66502-3391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-463-6505
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2025

Additional Information

Authorized Official

Authorized Official Last Name:
KEENE
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
LYNETTE
Authorized Official Title or Position:
VP, CYBERSECURITY, IT SECURITY
Authorized Official Telephone Number:
615-463-6523

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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