Healthcare Provider Details

I. General information

NPI: 1427603554
Provider Name (Legal Business Name): UNIVERSITY OF MEMPHIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 NORTH PARK LOOP SUITE 1000
MEMPHIS TN
38152
US

IV. Provider business mailing address

4055 NORTH PARK LOOP SUITE 1000
MEMPHIS TN
38152
US

V. Phone/Fax

Practice location:
  • Phone: 901-678-3209
  • Fax: 901-678-5630
Mailing address:
  • Phone: 901-678-3209
  • Fax: 901-678-5630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM MUELLER
Title or Position: INTERIM EXECUTIVE DIRECTOR PROCUREM
Credential:
Phone: 901-678-5348