Provider Demographics
NPI:1790707719
Name:KRONENBERG, MINDY E (PHD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:E
Last Name:KRONENBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5583 MURRAY RD
Mailing Address - Street 2:STE 208
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3841
Mailing Address - Country:US
Mailing Address - Phone:901-762-4488
Mailing Address - Fax:901-762-4497
Practice Address - Street 1:5583 MURRAY RD
Practice Address - Street 2:STE 208
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3841
Practice Address - Country:US
Practice Address - Phone:901-762-4488
Practice Address - Fax:901-762-4497
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA971103T00000X, 103TC2200X
TN2974103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1068403Medicaid
LA4H365Medicare PIN
LA1068403Medicaid