Healthcare Provider Details

I. General information

NPI: 1821448390
Provider Name (Legal Business Name): SHALONDA NAKIA ADAMS-YOUNG PEER SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N CLEVELAND ST
MEMPHIS TN
38104-2002
US

IV. Provider business mailing address

905 SPRINGDALE RUN DR
MEMPHIS TN
38108-3342
US

V. Phone/Fax

Practice location:
  • Phone: 800-274-1843
  • Fax:
Mailing address:
  • Phone: 901-314-0856
  • Fax: 901-805-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberL000000017975
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number000-1180
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: