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133 Indian Lake Rd Ste 204 Hendersonville TN 37075-3883 | |
| (615) 338-6341 | |
| (615) 338-6342 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 133 Indian Lake Rd Ste 204, Hendersonville, Tennessee |
| Authorized Official Name and Position | Mari Alexander (CEO) |
| Authorized Official Contact | 6153386341 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
133 Indian Lake Rd Ste 204 Hendersonville TN 37075-3883 Ph: (615) 338-6341 | 133 Indian Lake Rd Ste 204 Hendersonville TN 37075-3883 Ph: (615) 338-6341 |
| NPI Number | 1417387903 |
|---|---|
| Provider Enumeration Date | 11/19/2013 |
| Last Update Date | 06/26/2020 |
| Certification Date | 06/26/2020 |
| Medicare PECOS PAC ID | 6406277847 |
|---|---|
| Medicare Enrollment ID | O20200610002804 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1417387903 | NPI | - | NPPES |
| 5224021-00 | Medicaid | MD | |
| Q009156 | Medicaid | TN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | 10000002768 (Tennessee) | Primary |
| Provider Name | Christina Polk |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1457516502 PECOS PAC ID: 0244463826 Enrollment ID: I20150820011538 |
| Provider Name | Hector Benitez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1083222558 PECOS PAC ID: 2466861711 Enrollment ID: I20210517002567 |
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