Provider Demographics
NPI:1811191950
Name:CLOVER, KIM (EDD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:CLOVER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 STAGE OAKS DR STE 4
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3895
Mailing Address - Country:US
Mailing Address - Phone:901-387-0026
Mailing Address - Fax:901-552-4737
Practice Address - Street 1:6551 STAGE OAKS DR STE 4
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-3895
Practice Address - Country:US
Practice Address - Phone:901-387-0026
Practice Address - Fax:901-552-4737
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
TN472101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103856OtherVALUE OPTIONS TRICARE