Provider Demographics
NPI:1154509958
Name:LIFELINE CENTER, PLLC
Entity Type:Organization
Organization Name:LIFELINE CENTER, PLLC
Other - Org Name:LIFELINE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:865-981-7400
Mailing Address - Street 1:294 GAMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4943
Mailing Address - Country:US
Mailing Address - Phone:865-981-7400
Mailing Address - Fax:
Practice Address - Street 1:294 GAMBLE AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4943
Practice Address - Country:US
Practice Address - Phone:865-981-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN686101YP2500X
TN1002103TH0100X
TN38761041C0700X
TN46841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G705020Medicare PIN