Healthcare Provider Details

I. General information

NPI: 1639239791
Provider Name (Legal Business Name): TELLICO BAY COUNSELING & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 DAWSON ST
VONORE TN
37885-2416
US

IV. Provider business mailing address

104 DAWSON ST
VONORE TN
37885-2416
US

V. Phone/Fax

Practice location:
  • Phone: 423-884-2479
  • Fax: 423-884-2491
Mailing address:
  • Phone: 423-884-2479
  • Fax: 423-884-2491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC0000001953
License Number StateTN

VIII. Authorized Official

Name: SHIRLEY AMANDA SEXTON
Title or Position: CEO
Credential: MS, MHC, NCC
Phone: 423-884-2479