MEDICARE: HOLLY J WEST L.P.C./MHSP

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	101YP2500X	Professional Counselor	LPC0000002579	TN
2	171M00000X	Case Manager/Care Coordinator

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3376955	OTHER	TN	GROUP MEDICARE

General Provider Information

NPI Number	:	1760673727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY J WEST L.P.C./MHSP

Provider Business Mailing Address
First Line	:	191 GREEN HILL RD
Second Line	:
City	:	PLEASANT SHADE
State	:	TN
Zip	:	37145-3342
Country	:	US
Telephone Number	:	615-774-3223
Fax Number	:	615-774-3223

Provider Business Practice Location Address
First Line	:	1432 W MAIN ST
Second Line	:	SUITE 402
City	:	LEBANON
State	:	TN
Zip	:	37087-1323
Country	:	US
Telephone Number	:	615-444-1880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	11/16/2010

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