Healthcare Provider Details

I. General information

NPI: 1790707719
Provider Name (Legal Business Name): MINDY E KRONENBERG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5583 MURRAY RD STE 208
MEMPHIS TN
38119-3841
US

IV. Provider business mailing address

5583 MURRAY RD STE 208
MEMPHIS TN
38119-3841
US

V. Phone/Fax

Practice location:
  • Phone: 901-762-4488
  • Fax: 901-762-4497
Mailing address:
  • Phone: 901-762-4488
  • Fax: 901-762-4497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number971
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number971
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2974
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2974
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: