Healthcare Provider Details

I. General information

NPI: 1720859762
Provider Name (Legal Business Name): LIDEADERICK LAMAR GREGORY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

2537 PRINCETON AVE
MEMPHIS TN
38112-2726
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 901-483-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number239601
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: