Basic Information
Provider Information | |||||||||
NPI: | 1760838197 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRONTIER HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TRACES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1167 SPRATLIN PARK DR | ||||||||
Address2: |   | ||||||||
City: | GRAY | ||||||||
State: | TN | ||||||||
PostalCode: | 376156205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234673600 | ||||||||
FaxNumber: | 4234673644 | ||||||||
Practice Location | |||||||||
Address1: | 2001 STONEBROOK PL | ||||||||
Address2: |   | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376604000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232241000 | ||||||||
FaxNumber: | 4234673644 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2016 | ||||||||
LastUpdateDate: | 05/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KIDD | ||||||||
AuthorizedOfficialFirstName: | TERESA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 4234673600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FRONTIER HEALTH | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | SO/11429A | TN | Y |   | Agencies | Foster Care Agency |   |
No ID Information.