Basic Information
| Provider Information | |||||||||
| NPI: | 1457588592 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORTWOOD CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ROSEWOOD 3 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1028 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232666751 | ||||||||
| FaxNumber: | 4237634650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 OLD RINGGOLD RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374045444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232666751 | ||||||||
| FaxNumber: | 4237634650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | QUEEN-PENNINGTON | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4232666751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MENTAL HEALTH CENTERS & CLINICS OF FORTWOOD CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | L000000003955 | TN | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3399761 | 05 | TN | MEDICAID |