Provider Demographics
NPI:1649272352
Name:TAMARACK CENTER, INC.
Entity type:Organization
Organization Name:TAMARACK CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:WOODROW
Authorized Official - Last Name:BRILL
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:276-591-1133
Mailing Address - Street 1:800 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-3916
Mailing Address - Country:US
Mailing Address - Phone:276-591-1122
Mailing Address - Fax:276-591-1150
Practice Address - Street 1:800 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3916
Practice Address - Country:US
Practice Address - Phone:276-591-1122
Practice Address - Fax:276-591-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA08100002356103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4037985OtherBCBS TN
VA007727OtherVALUE OPTIONS
VA056271OtherTRIGON
VA056271OtherTRIGON
VA007727OtherVALUE OPTIONS