MEDICARE: FAHDEELA MEMON PSYD

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	36898	TX

General Provider Information

NPI Number	:	1841702636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAHDEELA MEMON PSYD

Provider Business Mailing Address
First Line	:	PO BOX 2257
Second Line	:
City	:	CHESTERTON
State	:	IN
Zip	:	46304-0357
Country	:	US
Telephone Number	:	219-926-8320
Fax Number	:

Provider Business Practice Location Address
First Line	:	2603 AUGUSTA DR STE 260
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77057-5638
Country	:	US
Telephone Number	:	713-487-9310
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2017
Last Update Date	:	11/01/2017

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