Provider Demographics
NPI:1548516446
Name:DUCKWORTH, CODY RAINE (PSYD)
Entity type:Individual
Prefix:DR
First Name:CODY
Middle Name:RAINE
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8065 SAG HARBOR CIR
Mailing Address - Street 2:APT 102
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-5998
Mailing Address - Country:US
Mailing Address - Phone:301-988-1588
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-28
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001262103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical