1073872776 NPI number — ETSU BEHAVIORAL HEALTH AND WELLNESS CLINIC

Table of content: (NPI 1073872776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073872776 NPI number — ETSU BEHAVIORAL HEALTH AND WELLNESS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ETSU BEHAVIORAL HEALTH AND WELLNESS CLINIC
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:
1073872776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 UNIVERSITY PARKWAY, CAMPUS BOX 70416
Provider Second Line Business Mailing Address:
139 LUCILLE CLEMENT HALL
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-439-7777
Provider Business Mailing Address Fax Number:
423-439-7780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
807 UNIVERSITY PKWY
Provider Second Line Business Practice Location Address:
139 LUCILLE CLEMENT HALL
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37614-6500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-439-7777
Provider Business Practice Location Address Fax Number:
423-439-7780
Provider Enumeration Date:
05/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLAND
Authorized Official First Name:
KERRY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
423-439-7777

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  9378 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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