1518021591 NPI number — VICKIE RENEA BREWER

Table of content: (NPI 1518021591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518021591 NPI number — VICKIE RENEA BREWER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICKIE RENEA BREWER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTER FOR PEDIATRIC NEUROPSYCHOLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518021591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 WASHINGTON AVE
Provider Second Line Business Mailing Address:
SUITE P235
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38105-4550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-287-5220
Provider Business Mailing Address Fax Number:
901-287-4502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 N DUNLAP ST
Provider Second Line Business Practice Location Address:
BOX 18
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38103-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-287-5220
Provider Business Practice Location Address Fax Number:
901-287-4502
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASPALL
Authorized Official First Name:
JOB
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
901-287-5220

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  P2103 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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