Healthcare Provider Details

I. General information

NPI: 1821742313
Provider Name (Legal Business Name): MARTHA MABONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 SHELBY OAKS DR
MEMPHIS TN
38134-7315
US

IV. Provider business mailing address

5810 SHELBY OAKS DR
MEMPHIS TN
38134-7315
US

V. Phone/Fax

Practice location:
  • Phone: 901-648-9354
  • Fax:
Mailing address:
  • Phone: 901-648-9354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: