Basic Information
| Provider Information | |||||||||
| NPI: | 1538147590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENEGAR | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | ELISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENEGAR-HAGAMAN | ||||||||
| OtherFirstName: | LAUREL | ||||||||
| OtherMiddleName: | ELISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6350 W A J HWY | ||||||||
| Address2: | DEPARTMENT 100 | ||||||||
| City: | TALBOTT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378778605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553565 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 6350 W ANDREW JOHNSON HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | TALBOTT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235877337 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | PE1467 | TN | Y | Behavioral Health & Social Service Providers | Psychologist | School |
ID Information
| ID | Type | State | Issuer | Description | 5441416 | 05 | TN | MEDICAID |