Provider Demographics
NPI:1932221496
Name:BAUSCH, ERIC J (LPC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:BAUSCH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3641 YOUTH TOWN RD
Mailing Address - Street 2:
Mailing Address - City:PINSON
Mailing Address - State:TN
Mailing Address - Zip Code:38366-9804
Mailing Address - Country:US
Mailing Address - Phone:731-988-5251
Mailing Address - Fax:731-427-5605
Practice Address - Street 1:3641 YOUTH TOWN RD
Practice Address - Street 2:
Practice Address - City:PINSON
Practice Address - State:TN
Practice Address - Zip Code:38366-9804
Practice Address - Country:US
Practice Address - Phone:731-988-5251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3358101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ013645Medicaid