Provider Demographics
NPI:1720097975
Name:RIVENDELL CENTER LLC
Entity Type:Organization
Organization Name:RIVENDELL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:865-681-4914
Mailing Address - Street 1:120 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-6051
Mailing Address - Country:US
Mailing Address - Phone:865-681-4914
Mailing Address - Fax:865-977-9573
Practice Address - Street 1:216 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-0537
Practice Address - Country:US
Practice Address - Phone:865-681-4914
Practice Address - Fax:865-977-9573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000039631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3922162Medicaid
TN3922162Medicaid