Provider Demographics
NPI:1285660621
Name:PAUL, CONNIE S (PHD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:PAUL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:5154 STAGE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3118
Mailing Address - Country:US
Mailing Address - Phone:901-372-9133
Mailing Address - Fax:901-372-1015
Practice Address - Street 1:5154 STAGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3118
Practice Address - Country:US
Practice Address - Phone:901-372-9133
Practice Address - Fax:901-372-1015
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP772103G00000X, 103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4067036OtherBCBS OF TN MEDICAL
TN3682508Medicaid
2134263OtherCIGNA BEHAVIORAL HEALTH
TN4053320OtherBCBS OF TN MENTAL HEALTH
TN4053320OtherBCBS OF TN MENTAL HEALTH