=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407614662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRETT MATTHEW KLEINHANS LPC-MHSP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2024
-----------------------------------------------------
Last Update Date | 03/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3032 SAGEGRASS DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37777-3572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-816-4309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3032 SAGEGRASS DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37777-3572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-816-4309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC0000006418
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------