Basic Information
| Provider Information | |||||||||
| NPI: | 1790811149 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH CENTERS & CLINICS OF TENNESSEE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FORTWOOD CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6049 SHALLOWFORD ROAD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232666751 | ||||||||
| FaxNumber: | 4237634650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1028 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232666751 | ||||||||
| FaxNumber: | 4237634650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 10/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | QUEEN-PENNINGTON | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4232666751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | L214-076-1367 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.