Provider Demographics
NPI:1639835572
Name:REDDY, TINA I (LADAC II, NCAC I)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:I
Last Name:REDDY
Suffix:
Gender:F
Credentials:LADAC II, NCAC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-4287
Mailing Address - Country:US
Mailing Address - Phone:615-992-6504
Mailing Address - Fax:615-800-8956
Practice Address - Street 1:320 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4287
Practice Address - Country:US
Practice Address - Phone:615-992-6504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1070101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN84-2779012Medicaid