Provider Demographics
NPI:1811719834
Name:PEDIATRIC PSYCHIATRIC PROFESSIONAL LLC
Entity type:Organization
Organization Name:PEDIATRIC PSYCHIATRIC PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RANDALE
Authorized Official - Last Name:FRITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:318-527-9322
Mailing Address - Street 1:PO BOX 17452
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-0452
Mailing Address - Country:US
Mailing Address - Phone:318-527-9322
Mailing Address - Fax:901-425-9726
Practice Address - Street 1:1661 INTERNATIONAL DR STE 400
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-1431
Practice Address - Country:US
Practice Address - Phone:713-628-8199
Practice Address - Fax:901-425-9726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty