Healthcare Provider Details

I. General information

NPI: 1417258625
Provider Name (Legal Business Name): PSYCAMORE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 CLARICE DR
MEMPHIS TN
38109-4627
US

IV. Provider business mailing address

563 CLARICE DR
MEMPHIS TN
38109-4627
US

V. Phone/Fax

Practice location:
  • Phone: 901-345-0637
  • Fax:
Mailing address:
  • Phone: 901-345-0637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberC5871
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License NumberC5871
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberC5871
License Number StateMS

VIII. Authorized Official

Name: MR. JERRY HAMILTON
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 662-349-2818