Provider Demographics
NPI:1043374564
Name:FRONTIER HEALTH
Entity Type:Organization
Organization Name:FRONTIER HEALTH
Other - Org Name:HAWKINS COUNTY MENTAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:423-467-3600
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:101 LENA DR
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-2951
Practice Address - Country:US
Practice Address - Phone:423-272-9239
Practice Address - Fax:423-272-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL 214-076-1416251B00000X, 251S00000X, 261QM0801X
TN370261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-4762-2Medicaid
TNSAME AS MEDICARE #SMedicaid
TN3689293Medicare ID - Type UnspecifiedFOR PHDS
TN3729687Medicare ID - Type UnspecifiedFOR MDS
VA49-4762-2Medicaid