Healthcare Provider Details

I. General information

NPI: 1225103914
Provider Name (Legal Business Name): FAMILY SERVICES OF THE MID-SOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 POPLAR AVE
MEMPHIS TN
38112-3246
US

IV. Provider business mailing address

2430 POPLAR AVE
MEMPHIS TN
38112-3246
US

V. Phone/Fax

Practice location:
  • Phone: 901-324-3637
  • Fax: 901-324-9114
Mailing address:
  • Phone: 901-324-3637
  • Fax: 901-324-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberL214 096 6397
License Number StateTN

VIII. Authorized Official

Name: MR. BRIAN O'MALLEY
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW
Phone: 901-324-3637