Provider Demographics
NPI:1649358680
Name:CARPENTER, MARY B (LCSW CEAP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:B
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:LCSW CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5384 POPLAR AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119
Mailing Address - Country:US
Mailing Address - Phone:901-762-0383
Mailing Address - Fax:901-762-0385
Practice Address - Street 1:5384 POPLAR AVE
Practice Address - Street 2:STE 105
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119
Practice Address - Country:US
Practice Address - Phone:901-762-0383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000599104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3690033Medicaid
3926899Medicare ID - Type Unspecified