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General NPI Number Information
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NPI Number | 1043728405
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Entity Type | Organization
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Legal Business Name | PAPILLON BEHAVIORAL HEALTH, LLC
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Dates
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Enumeration Date | 01/18/2018
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Last Update Date | 06/07/2018
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Provider Practice Location Address
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Address Line | 2514 1/2 WESLEY ST STE 2
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City | JOHNSON CITY
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State | TN
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Zip | 37601
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Country | US
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Telephone | 423-529-0385
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Fax | 423-414-2699
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Provider Business Mailing Address
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Address Line | 2514 1/2 WESLEY ST STE 2
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City | JOHNSON CITY
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State | TN
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Zip | 37601-1754
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Country | US
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Telephone | 423-529-0385
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Fax | 423-414-2699
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Authorized Official
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Title or Position | OWNER
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Name | DR. NICHOLAS PORTA
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Credential | PSYD
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Telephone | 423-529-0385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | P0000003473
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License Number State | TN
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