MEDICARE: WASHINGTON COUNTY COMMUNITY RESIDENTIAL SERVICES, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	L3324M60861502	TN

General Provider Information

NPI Number	:	1699813907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON COUNTY COMMUNITY RESIDENTIAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	215 UNIVERSITY PKWY
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-7339
Country	:	US
Telephone Number	:	239-282-7524
Fax Number	:	423-928-3680

Provider Business Practice Location Address
First Line	:	215 UNIVERSITY PKWY
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-7339
Country	:	US
Telephone Number	:	239-282-7524
Fax Number	:	423-928-3680

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. SUSAN ARWOOD
Credential	:
Telephone Number	:	423-552-4835

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	11/18/2021

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