Healthcare Provider Details

I. General information

NPI: 1992834204
Provider Name (Legal Business Name): BETHANY JOY ROUGEMONT GED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 N MAIN ST
TENNESSEE RIDGE TN
37178-4003
US

IV. Provider business mailing address

1330 N MAIN ST
TENNESSEE RIDGE TN
37178-4003
US

V. Phone/Fax

Practice location:
  • Phone: 931-721-3312
  • Fax:
Mailing address:
  • Phone: 931-721-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: