Provider Demographics
NPI:1972589638
Name:FAIN, WALTER WORLEY III (EDD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:WORLEY
Last Name:FAIN
Suffix:III
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:659 MORGANTON SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4763
Mailing Address - Country:US
Mailing Address - Phone:865-983-3348
Mailing Address - Fax:615-296-4440
Practice Address - Street 1:659 MORGANTON SQUARE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4763
Practice Address - Country:US
Practice Address - Phone:865-983-3348
Practice Address - Fax:615-296-4440
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNP0000001139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2004080OtherBLUE CROSS NUMBER
TN62-1424098-379200000OtherCHAMPUS NUMBER
TN62-1424098-379200000OtherCHAMPUS NUMBER