MEDICARE: OPTIMAL BEHAVIORAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	101Y00000X	Counselor	TN
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YP2500X	Professional Counselor
4	103TC0700X	Clinical Psychologist
5	1041C0700X	Clinical Social Worker
6	106H00000X	Marriage & Family Therapist
7	171M00000X	Case Manager/Care Coordinator
8	2084P0800X	Psychiatry Physician
9	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1447629126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL BEHAVIORAL, LLC

Provider Business Mailing Address
First Line	:	1311 CATHERINE DR
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 CATHERINE DR
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312
Country	:	US
Telephone Number	:	252-327-2365
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TOMEKIA BLACKMON
Credential	:
Telephone Number	:	252-327-2365

Provider Enumeration Date	:	09/23/2015
Last Update Date	:	09/23/2015

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