Healthcare Provider Details

I. General information

NPI: 1447698568
Provider Name (Legal Business Name): DR. MARY WANAT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 TRINITY RD STE 200
CORDOVA TN
38018-2735
US

IV. Provider business mailing address

8820 TRINITY RD STE 200
CORDOVA TN
38018-2735
US

V. Phone/Fax

Practice location:
  • Phone: 901-385-2342
  • Fax: 901-382-0140
Mailing address:
  • Phone: 901-385-2342
  • Fax: 901-382-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP2041
License Number StateTN

VIII. Authorized Official

Name: DR. MARY WANAT
Title or Position: OWNER
Credential: PHD
Phone: 901-756-8398