Healthcare Provider Details

I. General information

NPI: 1417603002
Provider Name (Legal Business Name): FT BHWC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3817 BEDFORD AVE STE 220
NASHVILLE TN
37215-2545
US

IV. Provider business mailing address

3817 BEDFORD AVE STE 220
NASHVILLE TN
37215-2545
US

V. Phone/Fax

Practice location:
  • Phone: 310-766-5860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL POOLOS
Title or Position: CEO
Credential:
Phone: 512-694-7848