Healthcare Provider Details

I. General information

NPI: 1760937163
Provider Name (Legal Business Name): TARA GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNION AVE SUITE 400
MEMPHIS TN
38112-4318
US

IV. Provider business mailing address

8577 S TRINITY PARK DR
OLIVE BRANCH MS
38654-6415
US

V. Phone/Fax

Practice location:
  • Phone: 662-902-0391
  • Fax:
Mailing address:
  • Phone: 662-902-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number000543136
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: