=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730578824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN STODDARD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2015
-----------------------------------------------------
Last Update Date | 12/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1635 CHESTNUT ST
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37408-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-400-7730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1635 CHESTNUT ST
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37408-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-400-7730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2849
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------