Basic Information
| Provider Information | |||||||||
| NPI: | 1114040847 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUDIE S CUSHMAN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIDTOWN MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 427 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381262023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015779400 | ||||||||
| FaxNumber: | 9015770207 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381262023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015779400 | ||||||||
| FaxNumber: | 9015770207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUSHMAN | ||||||||
| AuthorizedOfficialFirstName: | SUDIE | ||||||||
| AuthorizedOfficialMiddleName: | STOWERS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESCREENER | ||||||||
| AuthorizedOfficialTelephone: | 9015779400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M'ED | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.