Healthcare Provider Details

I. General information

NPI: 1013833367
Provider Name (Legal Business Name): IAN DEVILLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5842 HIGHWAY 30
BENTON TN
37307-4734
US

IV. Provider business mailing address

5842 HIGHWAY 30
BENTON TN
37307-4734
US

V. Phone/Fax

Practice location:
  • Phone: 423-283-5533
  • Fax:
Mailing address:
  • Phone: 423-241-3935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16763
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: