Provider Demographics
NPI:1124701115
Name:LY, TRISTAN
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TECH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-2747
Mailing Address - Country:US
Mailing Address - Phone:865-770-5551
Mailing Address - Fax:865-637-4362
Practice Address - Street 1:3105 ESSARY DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918
Practice Address - Country:US
Practice Address - Phone:865-637-9711
Practice Address - Fax:865-637-4362
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician