Provider Demographics
NPI:1407333842
Name:CLINICAL AND FORENSIC PSYCHOLOGY PROFESSIONAL LLC
Entity Type:Organization
Organization Name:CLINICAL AND FORENSIC PSYCHOLOGY PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COODINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-246-2104
Mailing Address - Street 1:PO BOX 5777
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5777
Mailing Address - Country:US
Mailing Address - Phone:865-246-2104
Mailing Address - Fax:865-246-2106
Practice Address - Street 1:812 N CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-1009
Practice Address - Country:US
Practice Address - Phone:615-446-8046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3431103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty