Provider Demographics
NPI:1942568019
Name:BEARDEN PSYCHOLOGICAL & WELLNESS CENTER, PLLC
Entity Type:Organization
Organization Name:BEARDEN PSYCHOLOGICAL & WELLNESS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:K. SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:865-584-4005
Mailing Address - Street 1:PO BOX 10372
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-0372
Mailing Address - Country:US
Mailing Address - Phone:865-584-4005
Mailing Address - Fax:865-584-5551
Practice Address - Street 1:813 S NORTHSHORE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-7594
Practice Address - Country:US
Practice Address - Phone:865-584-4005
Practice Address - Fax:865-584-5551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2498103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty