Healthcare Provider Details

I. General information

NPI: 1669104311
Provider Name (Legal Business Name): YOUR TENNESSEE COUNSELOR, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E SOUTH ST
COLLIERVILLE TN
38017-3018
US

IV. Provider business mailing address

30 MALLARD LN
ROSSVILLE TN
38066-1505
US

V. Phone/Fax

Practice location:
  • Phone: 901-647-0540
  • Fax:
Mailing address:
  • Phone: 901-647-0540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LAUREN ASHLEY
Title or Position: OWNER
Credential: LPC-MHSP
Phone: 901-647-0540