Basic Information
| Provider Information | |||||||||
| NPI: | 1396240347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRY | ||||||||
| FirstName: | THOM | ||||||||
| MiddleName: | EDD | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1167 SPRATLIN PARK DR | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376156205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | ERWIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376501234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237431470 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2018 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 7131 | TN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.