Provider Demographics
NPI:1790291334
Name:LIFECHANGERS OUTREACH
Entity Type:Organization
Organization Name:LIFECHANGERS OUTREACH
Other - Org Name:LIFECHANGERS IOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MDIV
Authorized Official - Phone:865-805-0567
Mailing Address - Street 1:404 HOLLY CT
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-5314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 WINFIELD DUNN PKWY
Practice Address - Street 2:
Practice Address - City:KODAK
Practice Address - State:TN
Practice Address - Zip Code:37764-2100
Practice Address - Country:US
Practice Address - Phone:865-805-0567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000021300261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder