Healthcare Provider Details

I. General information

NPI: 1225662166
Provider Name (Legal Business Name): RESTORE COUNSELING SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2020
Last Update Date: 03/01/2020
Certification Date: 03/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 FOWLER LN APT C8
CLINTON TN
37716-3236
US

IV. Provider business mailing address

1200 FOWLER LN APT C8
CLINTON TN
37716-3236
US

V. Phone/Fax

Practice location:
  • Phone: 865-770-3662
  • Fax:
Mailing address:
  • Phone: 865-770-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: RICHARD EARL LYONS II
Title or Position: FOUNDER
Credential: LPC
Phone: 865-770-3662