MEDICARE: OPTIMUM BEHAVIORAL HEALTH, INC.

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

General Provider Information

NPI Number	:	1689655268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM BEHAVIORAL HEALTH, INC.

Provider Business Mailing Address
First Line	:	5384 POPLAR AVE
Second Line	:	SUITE 313
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3609
Country	:	US
Telephone Number	:	901-237-0261
Fax Number	:	901-683-2058

Provider Business Practice Location Address
First Line	:	5384 POPLAR AVE
Second Line	:	SUITE 313
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3609
Country	:	US
Telephone Number	:	901-237-0261
Fax Number	:	901-683-2058

Authorized Official
Title or Position	:	OWNER
Name	:	W EDWARD AMOS
Credential	:	PH.D.
Telephone Number	:	901-237-0261

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	08/27/2014

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Practice Location Address:

5384 POPLAR AVE , SUITE 313
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1730161910 — ROBERT BLOOM PH.D.
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1942296827 — JAMES KEVIN MC DONALD RPH
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1497785182 — COMPREHENSIVE DIABETIC SOLUTIONS
Practice Location Address:

3251 POPLAR AVE , SUITE 23
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