MEDICARE: MR. ENOCH COLVIN IDOL

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	101YM0800X	Mental Health Counselor	2315	TN

General Provider Information

NPI Number	:	1871542068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ENOCH COLVIN IDOL

Provider Business Mailing Address
First Line	:	3105 ESSARY DRIVE
Second Line	:	ALTERNATIVE COUNSELING CENTER
City	:	KNOXVILLE
State	:	TN
Zip	:	37918-2409
Country	:	US
Telephone Number	:	865-687-8990
Fax Number	:	865-687-1190

Provider Business Practice Location Address
First Line	:	3105 ESSARY DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37918-2409
Country	:	US
Telephone Number	:	865-687-8990
Fax Number	:	865-687-1190

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	03/24/2008

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