Basic Information
Provider Information
NPI: 1841561446
EntityType: 2
ReplacementNPI:  
OrganizationName: FUNCTIONAL PATHWAYS PREFERRED OF TENNESSEE LLC
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Mailing Information
Address1: 10133 SHERRILL BLVD
Address2: SUITE 200
City: KNOXVILLE
State: TN
PostalCode: 379323347
CountryCode: US
TelephoneNumber: 8885312204
FaxNumber: 8552328604
Practice Location
Address1: 10133 SHERRILL BLVD
Address2: SUITE 200
City: KNOXVILLE
State: TN
PostalCode: 379323347
CountryCode: US
TelephoneNumber: 8885312204
FaxNumber: 8552328604
Other Information
ProviderEnumerationDate: 01/13/2012
LastUpdateDate: 01/19/2021
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AuthorizedOfficialLastName: MCCULLOUGH
AuthorizedOfficialFirstName: TRACI
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: CFO
AuthorizedOfficialTelephone: 8885312204
IsSoleProprietor:  
IsOrganizationSubpart: N
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NPICertificationDate: 01/19/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X  N193200000X MULTI-SPECIALTY GROUPRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 
235Z00000X  N193200000X MULTI-SPECIALTY GROUPSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist 
225100000X  Y193200000X MULTI-SPECIALTY GROUPRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
10009841705WI MEDICAID


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