Provider Demographics
NPI:1841610102
Name:STATUM, MARY ELIZABETH (LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:STATUM
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:HARRIS
Other - Last Name:STATUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC-MHSP
Mailing Address - Street 1:6630 SUMMER KNOLL CIR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-2875
Mailing Address - Country:US
Mailing Address - Phone:901-550-7867
Mailing Address - Fax:
Practice Address - Street 1:6630 SUMMER KNOLL CIR
Practice Address - Street 2:SUITE 101
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-2875
Practice Address - Country:US
Practice Address - Phone:901-550-7867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000002198101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional