Provider Demographics
NPI:1245398650
Name:KNOWLES-BAGWELL, TOMMY D (DMIN)
Entity Type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:D
Last Name:KNOWLES-BAGWELL
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 NOELTON AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-3232
Mailing Address - Country:US
Mailing Address - Phone:615-972-7652
Mailing Address - Fax:
Practice Address - Street 1:1024 NOELTON AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204-3232
Practice Address - Country:US
Practice Address - Phone:615-972-7652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNCPT 07101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4110514OtherBLUE CROSS ANDBLUE SHIELD