Provider Demographics
NPI:1780138313
Name:CENTERSTONE OF CHATTANOOGA
Entity type:Organization
Organization Name:CENTERSTONE OF CHATTANOOGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHULZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-279-6746
Mailing Address - Street 1:807 HURRICANE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4517
Mailing Address - Country:US
Mailing Address - Phone:423-702-0559
Mailing Address - Fax:
Practice Address - Street 1:807 HURRICANE CREEK RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4517
Practice Address - Country:US
Practice Address - Phone:423-702-0559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3397960Medicaid