Provider Demographics
NPI:1184625006
Name:CHRISTIAN PSYCHOLOGICAL CENTER, INC.
Entity type:Organization
Organization Name:CHRISTIAN PSYCHOLOGICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TONIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:901-458-6291
Mailing Address - Street 1:3950 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-7602
Mailing Address - Country:US
Mailing Address - Phone:901-458-6291
Mailing Address - Fax:901-323-4848
Practice Address - Street 1:3950 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-7602
Practice Address - Country:US
Practice Address - Phone:901-458-6291
Practice Address - Fax:901-323-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YP2500X, 1041C0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3925047Medicare PIN
TN3982192Medicare PIN