Basic Information
| Provider Information | |||||||||
| NPI: | 1407333842 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAL AND FORENSIC PSYCHOLOGY PROFESSIONAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5777 | ||||||||
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| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378025777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652462104 | ||||||||
| FaxNumber: | 8652462106 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 N CHARLOTTE ST | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370551009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154468046 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2018 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | KENDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COODINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8652462104 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3431 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.