Basic Information
| Provider Information | |||||||||
| NPI: | 1255088670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 4C THERAPEUTICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12749 HEATHLAND DR | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379344442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653866339 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 CENTER PARK DR STE 900 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379222133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652882112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2022 | ||||||||
| LastUpdateDate: | 03/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | REDFIELD | ||||||||
| AuthorizedOfficialFirstName: | JIBBY | ||||||||
| AuthorizedOfficialMiddleName: | LORD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8652882112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 03/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 4482 | 01 | TN | CASH BASE AGENCY | OTHER |