Provider Demographics
NPI:1497956825
Name:PEDIATRIC ADOLESCENT CENTER
Entity Type:Organization
Organization Name:PEDIATRIC ADOLESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT DESK MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:RENEA
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-757-3520
Mailing Address - Street 1:882 WILLOW TREE CIR STE 201
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-3118
Mailing Address - Country:US
Mailing Address - Phone:901-757-3520
Mailing Address - Fax:901-737-3807
Practice Address - Street 1:882 WILLOW TREE CIR STE 201
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-3118
Practice Address - Country:US
Practice Address - Phone:901-757-3520
Practice Address - Fax:901-737-3807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2676103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty