Healthcare Provider Details

I. General information

NPI: 1457971087
Provider Name (Legal Business Name): CLOVER MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 09/06/2023
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 QUITA CIR APT B
LEBANON TN
37087-4440
US

IV. Provider business mailing address

135 QUITA CIR APT B
LEBANON TN
37087-4440
US

V. Phone/Fax

Practice location:
  • Phone: 615-955-1729
  • Fax:
Mailing address:
  • Phone: 615-955-1729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN H DONNELLY
Title or Position: CEO/OWNER
Credential:
Phone: 615-955-1729