Healthcare Provider Details

I. General information

NPI: 1427200757
Provider Name (Legal Business Name): EAGLES PASSAGE THERAPEUTIC FARM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 RIDDLE RD
NEW MARKET TN
37820-4835
US

IV. Provider business mailing address

2605 RIDDLE RD
NEW MARKET TN
37820-4835
US

V. Phone/Fax

Practice location:
  • Phone: 865-932-3331
  • Fax: 865-932-3331
Mailing address:
  • Phone: 865-932-3331
  • Fax: 865-932-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW0000004526
License Number StateTN

VIII. Authorized Official

Name: LISA LYNN FRADY
Title or Position: MEMBER/CLINICAL DIRECTOR
Credential: LCSW
Phone: 865-932-3331