Healthcare Provider Details

I. General information

NPI: 1851136253
Provider Name (Legal Business Name): WEST TN NEUROPSYCHOLOGY & MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 CARRIAGE HOUSE DR STE D
JACKSON TN
38305-2299
US

IV. Provider business mailing address

382 CARRIAGE HOUSE DR STE D
JACKSON TN
38305-2299
US

V. Phone/Fax

Practice location:
  • Phone: 215-429-1730
  • Fax:
Mailing address:
  • Phone: 215-429-1730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: OUBAH ABDALLA
Title or Position: CEO
Credential:
Phone: 215-429-1730