Healthcare Provider Details

I. General information

NPI: 1902996721
Provider Name (Legal Business Name): YOUTH TOWN OF TENNESSEE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3641 YOUTH TOWN RD
PINSON TN
38366-9804
US

IV. Provider business mailing address

PO BOX 1385
JACKSON TN
38302-1385
US

V. Phone/Fax

Practice location:
  • Phone: 731-988-5251
  • Fax: 731-427-5605
Mailing address:
  • Phone: 731-988-5251
  • Fax: 731-427-5605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberI000000002836
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI000000002836
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0000000507
License Number StateTN

VIII. Authorized Official

Name: MR. NICK SUMMAR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 731-988-5251