Provider Demographics
NPI:1609961556
Name:HUGHLETT, MATTIE BOYD (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MATTIE
Middle Name:BOYD
Last Name:HUGHLETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4443 GARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-3512
Mailing Address - Country:US
Mailing Address - Phone:901-372-9442
Mailing Address - Fax:901-383-2501
Practice Address - Street 1:1420 UNION AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3695
Practice Address - Country:US
Practice Address - Phone:901-276-0220
Practice Address - Fax:901-383-2509
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW 00000032981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3920823Medicare ID - Type Unspecified