Provider Demographics
NPI:1225729890
Name:BYNUM, JUSTINE ELENNA
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ELENNA
Last Name:BYNUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 HALL DR
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-4585
Mailing Address - Country:US
Mailing Address - Phone:901-487-5002
Mailing Address - Fax:
Practice Address - Street 1:2250 HALL DR
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-4585
Practice Address - Country:US
Practice Address - Phone:901-487-5002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6499101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health