Healthcare Provider Details

I. General information

NPI: 1063992600
Provider Name (Legal Business Name): SPRINGS OF LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 BAKER STREET
JELLICO TN
37762
US

IV. Provider business mailing address

P.O. BOX 893
JELLICO TN
37762
US

V. Phone/Fax

Practice location:
  • Phone: 606-304-5395
  • Fax:
Mailing address:
  • Phone: 606-304-5395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1000000022735
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. CLIFF JAMISON BRANAM
Title or Position: DIRECTOR
Credential:
Phone: 865-406-4018