MEDICARE: TRICARE BEHAVORIAL HEALTH LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	L 2(14)M2-106-1633	TN
2	251S00000X	Community/Behavioral Health Agency	L 2(14)M2-106-1632	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L 2(14)M2-106-1633	OTHER	TN	TRICARE BRISTOL LICENSE
2	L 2(14)M2-106-1632	OTHER	TN	STRESS CARE ASSOC LICENSE

General Provider Information

NPI Number	:	1891844973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRICARE BEHAVORIAL HEALTH LLC

Provider Business Mailing Address
First Line	:	4024 FORT HENRY DR
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-2028
Country	:	US
Telephone Number	:	423-239-4638
Fax Number	:	423-239-5249

Provider Business Practice Location Address
First Line	:	4024 FORT HENRY DR
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-2028
Country	:	US
Telephone Number	:	423-239-4638
Fax Number	:	423-239-5249

Authorized Official
Title or Position	:	CEO
Name	:	LOWELL BRUCE MCKEE
Credential	:
Telephone Number	:	423-239-2190

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	02/19/2008

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Directions to “TRICARE BEHAVORIAL HEALTH LLC ” Practice Location

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