Provider Demographics
NPI:1417337056
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:TENNESSEE DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-253-6710
Mailing Address - Street 1:315 DEADERICK ST FL 8
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37238-3000
Mailing Address - Country:US
Mailing Address - Phone:615-532-6530
Mailing Address - Fax:
Practice Address - Street 1:301 STEWARTS FERRY PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214-3340
Practice Address - Country:US
Practice Address - Phone:615-231-5147
Practice Address - Fax:615-886-9972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ017827Medicaid