Healthcare Provider Details

I. General information

NPI: 1588769442
Provider Name (Legal Business Name): CHILD & ADOLESCENT PSYCHIATRY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 CULLY RD #100
CORDOVA TN
38016
US

IV. Provider business mailing address

PO BOX 1000 DEPT 233
MEMPHIS TN
38148-0233
US

V. Phone/Fax

Practice location:
  • Phone: 901-752-1980
  • Fax: 901-309-8784
Mailing address:
  • Phone: 901-752-1980
  • Fax: 901-309-8784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3730256
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

Name: JERRY D HESTON
Title or Position: SENIOR PARTNER
Credential:
Phone: 901-752-1980