=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700223773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEARDEN BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2013
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8848 CEDAR SPRINGS LN SUITE 201
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37923-5415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-212-6600
-----------------------------------------------------
Fax | 865-313-2149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8848 CEDAR SPRINGS LN SUITE 201
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37923-5415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-212-6600
-----------------------------------------------------
Fax | 865-313-2149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. DAWN FORTICH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 865-212-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------