Provider Demographics
NPI:1528405925
Name:AGAPE YOUTH BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:AGAPE YOUTH BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-443-3336
Mailing Address - Street 1:1360 MACKEY BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3225
Mailing Address - Country:US
Mailing Address - Phone:423-443-3336
Mailing Address - Fax:423-464-7510
Practice Address - Street 1:1360 MACKEY BRANCH DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3225
Practice Address - Country:US
Practice Address - Phone:423-443-3336
Practice Address - Fax:423-464-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-27
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31714261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health