Healthcare Provider Details

I. General information

NPI: 1356617401
Provider Name (Legal Business Name): CREEKSIDE CENTER FOR DEPRESSION AND TMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 MURRAY GUARD DR SUITE B
JACKSON TN
38305-3742
US

IV. Provider business mailing address

174 MURRAY GUARD DR SUITE B
JACKSON TN
38305-3742
US

V. Phone/Fax

Practice location:
  • Phone: 731-660-0199
  • Fax: 731-660-3650
Mailing address:
  • Phone: 731-660-0199
  • Fax: 731-660-3650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. PEPPER B PRATT
Title or Position: PARTNER
Credential: PH.D., LPC, MHSP
Phone: 731-660-0199