Provider Demographics
NPI:1073872776
Name:ETSU BEHAVIORAL HEALTH AND WELLNESS CLINIC
Entity Type:Organization
Organization Name:ETSU BEHAVIORAL HEALTH AND WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:423-439-7777
Mailing Address - Street 1:807 UNIVERSITY PARKWAY, CAMPUS BOX 70416
Mailing Address - Street 2:139 LUCILLE CLEMENT HALL
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614
Mailing Address - Country:US
Mailing Address - Phone:423-439-7777
Mailing Address - Fax:423-439-7780
Practice Address - Street 1:807 UNIVERSITY PKWY
Practice Address - Street 2:139 LUCILLE CLEMENT HALL
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-6500
Practice Address - Country:US
Practice Address - Phone:423-439-7777
Practice Address - Fax:423-439-7780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TENNESSEE STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9378251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health