Healthcare Provider Details

I. General information

NPI: 1003664517
Provider Name (Legal Business Name): BOAZ RODERICK FUTCH PHD.PSY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

952 DECATUR ST
MEMPHIS TN
38107-2703
US

IV. Provider business mailing address

PO BOX 70700
MEMPHIS TN
38107-0700
US

V. Phone/Fax

Practice location:
  • Phone: 901-644-5713
  • Fax:
Mailing address:
  • Phone: 901-644-5713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: