Basic Information
| Provider Information | |||||||||
| NPI: | 1548516446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUCKWORTH | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | RAINE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8065 SAG HARBOR CIR | ||||||||
| Address2: | APT 102 | ||||||||
| City: | CORDOVA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380165998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019881588 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2012 | ||||||||
| LastUpdateDate: | 07/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 001262 | IA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.