Healthcare Provider Details

I. General information

NPI: 1700279080
Provider Name (Legal Business Name): FAIRHAVEN TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 N HOUSTON LEVEE RD
CORDOVA TN
38018-6614
US

IV. Provider business mailing address

890 N HOUSTON LEVEE RD
CORDOVA TN
38018-6614
US

V. Phone/Fax

Practice location:
  • Phone: 901-757-7979
  • Fax:
Mailing address:
  • Phone: 901-757-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number14387
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number14387
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number14387
License Number StateTN

VIII. Authorized Official

Name: JESSICA ANN GRAY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 901-757-7979