Healthcare Provider Details

I. General information

NPI: 1114040847
Provider Name (Legal Business Name): SUDIE S CUSHMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 LINDEN AVE
MEMPHIS TN
38126-2023
US

IV. Provider business mailing address

427 LINDEN AVE
MEMPHIS TN
38126-2023
US

V. Phone/Fax

Practice location:
  • Phone: 901-577-9400
  • Fax: 901-577-0207
Mailing address:
  • Phone: 901-577-9400
  • Fax: 901-577-0207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SUDIE STOWERS CUSHMAN
Title or Position: PRESCREENER
Credential: M'ED
Phone: 901-577-9400