Provider Demographics
NPI:1417258625
Name:PSYCAMORE, LLC
Entity Type:Organization
Organization Name:PSYCAMORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:662-349-2818
Mailing Address - Street 1:563 CLARICE DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-4627
Mailing Address - Country:US
Mailing Address - Phone:901-345-0637
Mailing Address - Fax:
Practice Address - Street 1:563 CLARICE DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109-4627
Practice Address - Country:US
Practice Address - Phone:901-345-0637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC5871261Q00000X, 261QA0005X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health