Healthcare Provider Details

I. General information

NPI: 1609424274
Provider Name (Legal Business Name): BRIGHT STAR CHILD AND ADOLESCENT PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 MORGANTON SQUARE DR
MARYVILLE TN
37801-4763
US

IV. Provider business mailing address

641 MORGANTON SQUARE DR
MARYVILLE TN
37801-4763
US

V. Phone/Fax

Practice location:
  • Phone: 865-724-1590
  • Fax: 865-724-1591
Mailing address:
  • Phone: 865-724-1592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA CABAGE
Title or Position: OWNER
Credential: APRN
Phone: 865-724-1590