Healthcare Provider Details

I. General information

NPI: 1619292885
Provider Name (Legal Business Name): DEBRA K MAIN MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 LANTANA RD
CROSSVILLE TN
38555-4900
US

IV. Provider business mailing address

352 LANTANA RD
CROSSVILLE TN
38555-4900
US

V. Phone/Fax

Practice location:
  • Phone: 931-707-8200
  • Fax:
Mailing address:
  • Phone: 931-707-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number05938
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC005461
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: