Healthcare Provider Details

I. General information

NPI: 1720422371
Provider Name (Legal Business Name): TYRA WATTS PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 LE CHATEAU COVE OPTIONAL
MEMPHIS TN
38125-0267
US

IV. Provider business mailing address

5080 LE CHATEAU CV
MEMPHIS TN
38125-3912
US

V. Phone/Fax

Practice location:
  • Phone: 901-921-6566
  • Fax: 888-551-0262
Mailing address:
  • Phone: 901-921-6566
  • Fax: 888-551-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5879
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: