Healthcare Provider Details

I. General information

NPI: 1497862411
Provider Name (Legal Business Name): MARY ANNE KNACK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE 116A4
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

6470 BELMONT CV
MEMPHIS TN
38135-9492
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 901-377-8684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberP0000001933
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberP0000001933
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: