Provider Demographics
NPI:1255358057
Name:OVERTON, MAX NAGLE (PHD)
Entity type:Individual
Prefix:DR
First Name:MAX
Middle Name:NAGLE
Last Name:OVERTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 MIDDLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-5035
Mailing Address - Country:US
Mailing Address - Phone:865-428-2193
Mailing Address - Fax:865-428-2090
Practice Address - Street 1:856 MIDDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5035
Practice Address - Country:US
Practice Address - Phone:865-428-2193
Practice Address - Fax:865-428-2090
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000000983103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3685358Medicaid
TN3685358Medicare ID - Type UnspecifiedMEDICARE