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General NPI Number Information
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NPI Number | 1760937163
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Entity Type | Individual
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Provider Name | TARA GORDON
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Gender | Female
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Dates
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Enumeration Date | 08/16/2016
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Last Update Date | 08/16/2016
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Provider Practice Location Address
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Address Line | 2400 UNION AVE SUITE 400
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City | MEMPHIS
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State | TN
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Zip | 38112-4318
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Country | US
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Telephone | 662-902-0391
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Fax |
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Provider Business Mailing Address
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Address Line | 8577 S TRINITY PARK DR
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-6415
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Country | US
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Telephone | 662-902-0391
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YS0200X
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Taxonomy Name | School Counselor
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License Number | 000543136
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License Number State | TN
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