Provider Demographics
NPI:1346759636
Name:ENSEMBLE RECOVERY ENTERPRISES, LLC
Entity Type:Organization
Organization Name:ENSEMBLE RECOVERY ENTERPRISES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEAVER
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHATTUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-770-3838
Mailing Address - Street 1:PO BOX 5777
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5777
Mailing Address - Country:US
Mailing Address - Phone:865-246-2104
Mailing Address - Fax:865-246-2106
Practice Address - Street 1:417 HOLLY ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-7815
Practice Address - Country:US
Practice Address - Phone:865-770-4003
Practice Address - Fax:865-246-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35501041C0700X
TN27892207R00000X
TN21354363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty