Provider Demographics
NPI:1689423733
Name:SOLOMON, SAVANNAH
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:SOLOMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CROCKETT AVE
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:TN
Mailing Address - Zip Code:37309-5266
Mailing Address - Country:US
Mailing Address - Phone:540-641-2962
Mailing Address - Fax:
Practice Address - Street 1:177 MOUSE CREEK RD NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3838
Practice Address - Country:US
Practice Address - Phone:540-641-2962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1119510106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician