Healthcare Provider Details

I. General information

NPI: 1295206514
Provider Name (Legal Business Name): HENRY ISAAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2018
Last Update Date: 12/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 COLONIAL RD STE 201
MEMPHIS TN
38117-4097
US

IV. Provider business mailing address

560 COLONIAL RD STE 201
MEMPHIS TN
38117-4097
US

V. Phone/Fax

Practice location:
  • Phone: 901-930-7397
  • Fax: 901-244-6528
Mailing address:
  • Phone: 901-930-7397
  • Fax: 901-244-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number04250
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: