Basic Information
| Provider Information | |||||||||
| NPI: | 1861790131 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH CENTERS & CLINICS OF TENNESSEE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FORTWOOD CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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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: | 1028 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232666751 | ||||||||
| FaxNumber: | 4237634650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2011 | ||||||||
| LastUpdateDate: | 03/10/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEDLEY | ||||||||
| AuthorizedOfficialFirstName: | H. | ||||||||
| AuthorizedOfficialMiddleName: | EARL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4232666751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMSW/ACSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.