=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467511774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARDNER PRITCHARD BROOKSBANK JR. SPE HEALTH SERVICE P
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4646 POPLAR AVENUE SUITE 434
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-767-0956
-----------------------------------------------------
Fax | 901-767-1956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 BREMINGTON PLACE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-458-0503
-----------------------------------------------------
Fax | 901-767-1956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 0000000016
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------