=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033815873
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2023
-----------------------------------------------------
Last Update Date | 09/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1860 WILMA RUDOLPH BLVD STE 111B
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37040-6750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-398-2123
-----------------------------------------------------
Fax | 931-233-4544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1860 WILMA RUDOLPH BLVD STE 111B
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37040-6750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-398-2123
-----------------------------------------------------
Fax | 931-233-4544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER-CLINICIAN
-----------------------------------------------------
Name | DEBORAH ANNE DAI'RE
-----------------------------------------------------
Credential | LPC-MHSP
-----------------------------------------------------
Telephone | 615-398-2123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------