Healthcare Provider Details

I. General information

NPI: 1528405925
Provider Name (Legal Business Name): AGAPE YOUTH BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2013
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 MACKEY BRANCH DR
CHATTANOOGA TN
37421-3225
US

IV. Provider business mailing address

1360 MACKEY BRANCH DR
CHATTANOOGA TN
37421-3225
US

V. Phone/Fax

Practice location:
  • Phone: 423-443-3336
  • Fax: 423-464-7510
Mailing address:
  • Phone: 423-443-3336
  • Fax: 423-464-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number31714
License Number StateTN

VIII. Authorized Official

Name: COURTNEY CANTRELL
Title or Position: CREDENTIALING
Credential:
Phone: 423-443-3336