1972184893 NPI number — ELLIS GAVIN REEF

Table of content: MS. CATHERINE MARIE CHRISTOFILAKOS LCPC (NPI 1699883611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972184893 NPI number — ELLIS GAVIN REEF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLIS GAVIN REEF
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:
Provider Other Organization Name Type Code:
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:
1972184893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5885 AIRLINE RD UNIT 914
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38002-5118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-317-7360
Provider Business Mailing Address Fax Number:
901-317-7585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6019 WALNUT GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-226-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2021

Additional Information

Authorized Official

Authorized Official Last Name:
REEF
Authorized Official First Name:
ELLIS
Authorized Official Middle Name:
GAVIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
901-317-7360

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00114675 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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