Healthcare Provider Details

I. General information

NPI: 1811719834
Provider Name (Legal Business Name): PEDIATRIC PSYCHIATRIC PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 INTERNATIONAL DR STE 400
MEMPHIS TN
38120-1431
US

IV. Provider business mailing address

PO BOX 17452
MEMPHIS TN
38187-0452
US

V. Phone/Fax

Practice location:
  • Phone: 713-628-8199
  • Fax: 901-425-9726
Mailing address:
  • Phone: 318-527-9322
  • Fax: 901-425-9726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES RANDALE FRITH
Title or Position: OPERATIONS MANAGER
Credential: LCSW
Phone: 318-527-9322