Provider Demographics
NPI:1689248965
Name:REDD, ROELA
Entity Type:Individual
Prefix:
First Name:ROELA
Middle Name:
Last Name:REDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 MORNINGSTAR LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1346
Mailing Address - Country:US
Mailing Address - Phone:865-338-5384
Mailing Address - Fax:
Practice Address - Street 1:207 N BOONE ST STE 13
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5659
Practice Address - Country:US
Practice Address - Phone:865-338-5384
Practice Address - Fax:865-338-5383
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5081101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional