MEDICARE: PANDORAS AWAKENING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor
3	106H00000X	Marriage & Family Therapist
4	163WP0808X	Psychiatric/Mental Health Registered Nurse
5	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1114583770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANDORAS AWAKENING

Provider Business Mailing Address
First Line	:	223 MADISON ST STE 102
Second Line	:
City	:	MADISON
State	:	TN
Zip	:	37115-3660
Country	:	US
Telephone Number	:	615-375-6896
Fax Number	:

Provider Business Practice Location Address
First Line	:	223 MADISON ST STE 102
Second Line	:
City	:	MADISON
State	:	TN
Zip	:	37115-3660
Country	:	US
Telephone Number	:	615-375-6896
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RENEE D BURWELL
Credential	:	LCSW, MPA, CST
Telephone Number	:	615-375-6896

Provider Enumeration Date	:	05/18/2019
Last Update Date	:	05/18/2019

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Directions to “PANDORAS AWAKENING ” Practice Location

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