Healthcare Provider Details

I. General information

NPI: 1962797399
Provider Name (Legal Business Name): GENERATIONS GAITHIER MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 NEAL ST SUITE 101
COOKEVILLE TN
38501-0942
US

IV. Provider business mailing address

375 NORROD LN
MONTEREY TN
38574-5485
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-8593
  • Fax:
Mailing address:
  • Phone: 931-787-0328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberLPN0000071144
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLPN0000071144
License Number StateTN

VIII. Authorized Official

Name: MS. DEBORAH JOYCE STEWART
Title or Position: L.P.N.
Credential: L.P.N.
Phone: 931-528-8593