First Name
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Last Name
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Date of birth
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Phone
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Email
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Seeking Treatment For
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Adderall
Alcohol
Barbiturate
Benzodiazepine
Cocaine/Crack
Fentanyl
Heroin
Hydrocodone
Inhalant
Marijuana
Meth
Oxycodone
Opioid
Prescription Drug
Xanax
Medication-Assisted Treatment (MAT)
Methadone
Pain Killers
Sleeping pills
Suboxone
Tobacco
Steroids
PCP
Medication Management
Inhalants
GHB
Ecstacy
Designer Drug(s)
Chronic Relapse
Bath Salts
Amphetamine
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Select Location
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BULLS GAP, TN
JOHNSON CITY, TN
WEBER CITY, VA
Weber City
Johnson City
Bulls Gap
Bulls gap
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Insurance Plan Name
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Insurance Type
Commercial
Private
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