Provider Demographics
NPI:1881621134
Name:FORTNER, BARRY V (PHD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:V
Last Name:FORTNER
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 1:100 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2146
Mailing Address - Country:US
Mailing Address - Phone:901-322-9080
Mailing Address - Fax:901-322-9097
Practice Address - Street 1:100 N HUMPHREYS BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2146
Practice Address - Country:US
Practice Address - Phone:901-322-9080
Practice Address - Fax:901-322-9097
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2365103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3981982Medicaid
MS00124541Medicaid
TN4041246OtherBCBS TN
TN3981982Medicaid