Basic Information
Provider Information | |||||||||
NPI: | 1013037159 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THERAPY & LEARNING CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 32 GARLAND DR | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383053602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316683322 | ||||||||
FaxNumber: | 7316642491 | ||||||||
Practice Location | |||||||||
Address1: | 32 GARLAND DR | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383053602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316683322 | ||||||||
FaxNumber: | 7316642491 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2007 | ||||||||
LastUpdateDate: | 04/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROSS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 7315415000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | PSS0000000110 | TN | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 0446690 | 05 | TN |   | MEDICAID | 1 320-017-9700 | 01 | TN | TN DEPT OF MENTAL HEALTH | OTHER | 4155645 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |