1124246145 NPI number — MR. RONALD WAYNE LAUDERDALE MSSW

Table of content: MR. RONALD WAYNE LAUDERDALE MSSW (NPI 1124246145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124246145 NPI number — MR. RONALD WAYNE LAUDERDALE MSSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAUDERDALE
Provider First Name:
RONALD
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124246145
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1104 WEST ADAIR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37918-1527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-688-3326
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5117 SCHUBERT RD STE #A
Provider Second Line Business Practice Location Address:
CHRISTIAN COUNSELING CENTER
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37912-3871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-689-3326
Provider Business Practice Location Address Fax Number:
865-689-3326
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  4847 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 138577 . This is a "VALUE OPTIMA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 5694663 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 737240000 . This is a "MAGELLAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 197473293284 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3101178 . This is a "BC BST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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