MEDICARE: MEMPHIS CENTER FOR MINDFUL LIVING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2519	TN

General Provider Information

NPI Number	:	1265950919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMPHIS CENTER FOR MINDFUL LIVING, LLC

Provider Business Mailing Address
First Line	:	4646 POPLAR AVE STE 435
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-4443
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4646 POPLAR AVE STE 435
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-4443
Country	:	US
Telephone Number	:	901-537-2900
Fax Number	:	901-537-2901

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. AMY CHRISTINE BALENTINE
Credential	:	PH.D.
Telephone Number	:	901-537-2900

Provider Enumeration Date	:	09/01/2017
Last Update Date	:	09/01/2017

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