=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285107003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RECOVERY ASSOCIATES GROUP, AT SOUTHWIND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2019
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3257 W SARAZENS CIR
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38125-0807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-590-4106
-----------------------------------------------------
Fax | 901-343-0792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3257 W SARAZENS CIR
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38125-0807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-590-4106
-----------------------------------------------------
Fax | 901-343-0792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SCHERRI N HENDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-618-4733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------