Healthcare Provider Details

I. General information

NPI: 1154509958
Provider Name (Legal Business Name): LIFELINE CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 GAMBLE AVE
MARYVILLE TN
37801-4943
US

IV. Provider business mailing address

294 GAMBLE AVE
MARYVILLE TN
37801-4943
US

V. Phone/Fax

Practice location:
  • Phone: 865-981-7400
  • Fax:
Mailing address:
  • Phone: 865-981-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number686
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3876
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4684
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1002
License Number StateTN

VIII. Authorized Official

Name: DR. NANCY JOY CARROLL
Title or Position: EXECUTIVE DIRECTOR/PSYCHOLOGIST
Credential: ED.D.
Phone: 865-981-7400