Provider Demographics
NPI:1730190463
Name:M NAN HAWKES PHD MED PSYCH GROUP
Entity type:Organization
Organization Name:M NAN HAWKES PHD MED PSYCH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:NAN
Authorized Official - Last Name:HAWKES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:901-751-3571
Mailing Address - Street 1:7655 POPLAR AVE
Mailing Address - Street 2:#365
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3957
Mailing Address - Country:US
Mailing Address - Phone:901-751-3571
Mailing Address - Fax:901-751-3572
Practice Address - Street 1:7655 POPLAR AVE
Practice Address - Street 2:#365
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3995
Practice Address - Country:US
Practice Address - Phone:901-751-3571
Practice Address - Fax:901-751-3572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3685330Medicare PIN