Provider Demographics
NPI:1508136540
Name:IMASUEN, FESTUS O
Entity Type:Individual
Prefix:
First Name:FESTUS
Middle Name:O
Last Name:IMASUEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-0249
Mailing Address - Country:US
Mailing Address - Phone:615-884-5669
Mailing Address - Fax:615-884-5670
Practice Address - Street 1:5653 FRIST BLVD
Practice Address - Street 2:SUITE 740
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2062
Practice Address - Country:US
Practice Address - Phone:615-884-5669
Practice Address - Fax:615-884-5670
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000000847106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist