Basic Information
| Provider Information | |||||||||
| NPI: | 1548380991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHOLSTON | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | KERRIE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0000005776 | TN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.