Provider Demographics
NPI:1881174787
Name:RESTORE LIFE BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:RESTORE LIFE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERVETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:615-348-5806
Mailing Address - Street 1:100 COUNTRY CLUB DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-4376
Mailing Address - Country:US
Mailing Address - Phone:615-348-5806
Mailing Address - Fax:615-285-8130
Practice Address - Street 1:100 COUNTRY CLUB DR STE 200
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075
Practice Address - Country:US
Practice Address - Phone:615-348-5806
Practice Address - Fax:615-285-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN62891041C0700X
TN3685261QM0801X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027516Medicaid