Basic Information
Provider Information | |||||||||
NPI: | 1285660621 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAUL | ||||||||
FirstName: | CONNIE | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5154 STAGE RD | ||||||||
Address2: | SUITE 102 | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381343118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9013729133 | ||||||||
FaxNumber: | 9013721015 | ||||||||
Practice Location | |||||||||
Address1: | 5154 STAGE RD | ||||||||
Address2: | SUITE 102 | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381343118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9013729133 | ||||||||
FaxNumber: | 9013721015 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | P772 | TN | X |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   | 103TC0700X | P772 | TN | X |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TH0100X | P772 | TN | X |   | Behavioral Health & Social Service Providers | Psychologist | Health Service |
ID Information
ID | Type | State | Issuer | Description | 4067036 | 01 | TN | BCBS OF TN MEDICAL | OTHER | 3682508 | 05 | TN |   | MEDICAID | 2134263 | 01 |   | CIGNA BEHAVIORAL HEALTH | OTHER | 4053320 | 01 | TN | BCBS OF TN MENTAL HEALTH | OTHER |