Provider Demographics
NPI:1467511774
Name:BROOKSBANK, GARDNER PRITCHARD JR (SPE HEALTH SERVICE P)
Entity Type:Individual
Prefix:MR
First Name:GARDNER
Middle Name:PRITCHARD
Last Name:BROOKSBANK
Suffix:JR
Gender:M
Credentials:SPE HEALTH SERVICE P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 BREMINGTON PLACE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111
Mailing Address - Country:US
Mailing Address - Phone:901-458-0503
Mailing Address - Fax:901-767-1956
Practice Address - Street 1:4646 POPLAR AVENUE
Practice Address - Street 2:SUITE 434
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117
Practice Address - Country:US
Practice Address - Phone:901-767-0956
Practice Address - Fax:901-767-1956
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000016103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist