1639239791 NPI number — TELLICO BAY COUNSELING & WELLNESS CENTER

Table of content: (NPI 1639239791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639239791 NPI number — TELLICO BAY COUNSELING & WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TELLICO BAY COUNSELING & WELLNESS CENTER
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:
1639239791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 DAWSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VONORE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37885-2416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-884-2479
Provider Business Mailing Address Fax Number:
423-884-2491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 DAWSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VONORE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37885-2416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-884-2479
Provider Business Practice Location Address Fax Number:
423-884-2491
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SEXTON
Authorized Official First Name:
SHIRLEY
Authorized Official Middle Name:
AMANDA
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
423-884-2479

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LPC0000001953 , 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)





Copyright © 2007-2025 www.npivalidator.com