Provider Demographics
NPI:1316049893
Name:WINBORN, MARK DOUGLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:WINBORN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 POPLAR AVE
Mailing Address - Street 2:SUITE 1633
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38157-0101
Mailing Address - Country:US
Mailing Address - Phone:901-766-1890
Mailing Address - Fax:901-766-1890
Practice Address - Street 1:5050 POPLAR AVE
Practice Address - Street 2:SUITE 1633
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38157-0101
Practice Address - Country:US
Practice Address - Phone:901-766-1890
Practice Address - Fax:901-766-1890
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1316103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3680904Medicaid
TN3680904Medicaid
TN3680904Medicare ID - Type Unspecified