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General NPI Number Information
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NPI Number | 1063992600
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Entity Type | Organization
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Legal Business Name | SPRINGS OF LIFE
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Dates
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Enumeration Date | 08/14/2018
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Last Update Date | 08/14/2018
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Provider Practice Location Address
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Address Line | 185 BAKER STREET
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City | JELLICO
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State | TN
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Zip | 37762
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Country | US
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Telephone | 606-304-5395
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Fax |
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Provider Business Mailing Address
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Address Line | P.O. BOX 893
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City | JELLICO
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State | TN
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Zip | 37762
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Country | US
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Telephone | 606-304-5395
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. CLIFF JAMISON BRANAM
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Credential |
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Telephone | 865-406-4018
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TR0400X
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Taxonomy Name | Rehabilitation Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1000000022735
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License Number State | TN
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