Provider Demographics
NPI:1598098527
Name:MINDRUP, ROBERT MATTHEW (PSYD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MATTHEW
Last Name:MINDRUP
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-5654
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:4330 MAYNARDVILLE HWY
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807-3618
Practice Address - Country:US
Practice Address - Phone:865-992-3849
Practice Address - Fax:865-992-5166
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2924103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical