Provider Demographics
NPI:1801038104
Name:PRINCE, DARRELL NATHANAEL (ADIV)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:NATHANAEL
Last Name:PRINCE
Suffix:
Gender:M
Credentials:ADIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 UNION AVENUE EXT
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-4436
Mailing Address - Country:US
Mailing Address - Phone:901-320-6146
Mailing Address - Fax:901-320-6101
Practice Address - Street 1:2714 UNION AVENUE EXT
Practice Address - Street 2:SUITE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-4436
Practice Address - Country:US
Practice Address - Phone:901-320-6146
Practice Address - Fax:901-320-6101
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health