Healthcare Provider Details

I. General information

NPI: 1205103348
Provider Name (Legal Business Name): ASHLEY LAURA ANNESTEDT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 07/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 JEFFERSON AVE ROOM 135
MEMPHIS TN
38105-5003
US

IV. Provider business mailing address

711 JEFFERSON AVE ROOM 283A
MEMPHIS TN
38105-5003
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-6511
  • Fax: 901-448-7097
Mailing address:
  • Phone: 901-448-6511
  • Fax: 901-448-7097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5769
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: