Basic Information
| Provider Information | |||||||||
| NPI: | 1235334350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNAWAY | ||||||||
| FirstName: | MARCELLA | ||||||||
| MiddleName: | HORN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HORN | ||||||||
| OtherFirstName: | MARCELLA | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4068 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378024068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 262 CHEROKEE PROFESSIONAL PARK | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659844223 | ||||||||
| FaxNumber: | 8656811789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | P2872 (PROV) | TN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | P2872 | TN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | P2872 | TN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TB0200X | P2872 | TN | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
| ID | Type | State | Issuer | Description | 1517021 | 05 | TN | MEDICAID |