Provider Demographics
NPI:1427200757
Name:EAGLES PASSAGE THERAPEUTIC FARM, LLC
Entity Type:Organization
Organization Name:EAGLES PASSAGE THERAPEUTIC FARM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FRADY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:865-932-3331
Mailing Address - Street 1:2605 RIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:TN
Mailing Address - Zip Code:37820-4835
Mailing Address - Country:US
Mailing Address - Phone:865-932-3331
Mailing Address - Fax:865-932-3331
Practice Address - Street 1:2605 RIDDLE RD
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:TN
Practice Address - Zip Code:37820-4835
Practice Address - Country:US
Practice Address - Phone:865-932-3331
Practice Address - Fax:865-932-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-17
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000045261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN264470000OtherMAGELLAN
TN4208400OtherBCBST
TN263470730OtherHUMANA-MILITARY
TN5389124OtherAETNA
TN2088872OtherCIGNA
TN39278701Medicare PIN