Provider Demographics
NPI:1013421130
Name:NORMAN, MELVIN THOMAS JR (BA/LADAC2/QCS/NCAC1/)
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:THOMAS
Last Name:NORMAN
Suffix:JR
Gender:M
Credentials:BA/LADAC2/QCS/NCAC1/
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 RACINE ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-2729
Mailing Address - Country:US
Mailing Address - Phone:901-230-4047
Mailing Address - Fax:
Practice Address - Street 1:119 RACINE ST STE 105
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-2729
Practice Address - Country:US
Practice Address - Phone:901-230-4047
Practice Address - Fax:901-443-5089
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC0000000722101YA0400X
TN722101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN054462778Medicaid