Provider Demographics
NPI:1538284799
Name:DETRIE, PAMELA MAXINE (PHD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:MAXINE
Last Name:DETRIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N WILLETT ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-5122
Mailing Address - Country:US
Mailing Address - Phone:901-278-7198
Mailing Address - Fax:
Practice Address - Street 1:2000 N PARKWAY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-1624
Practice Address - Country:US
Practice Address - Phone:901-843-3128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000002491103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist