Provider Demographics
NPI:1508977448
Name:SUMLIN, OTIS (LCSW)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:
Last Name:SUMLIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 LYNNFIELD RD
Mailing Address - Street 2:SUITE 245
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 LYNNFIELD RD
Practice Address - Street 2:SUITE 245
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5801
Practice Address - Country:US
Practice Address - Phone:901-818-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW32411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4080319OtherB/C
342576OtherMANAGED HEALTH N/W
342576OtherMANAGED HEALTH N/W