Healthcare Provider Details

I. General information

NPI: 1639775711
Provider Name (Legal Business Name): JOHN M. DUFFEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2020
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 RIVERCHASE DR STE 100A
PHENIX CITY AL
36867-7497
US

IV. Provider business mailing address

5009 RIVERCHASE DR STE 100A
PHENIX CITY AL
36867-7497
US

V. Phone/Fax

Practice location:
  • Phone: 334-540-4401
  • Fax: 334-408-2100
Mailing address:
  • Phone: 334-540-4401
  • Fax: 334-408-2100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN MICHAEL DUFFEY I
Title or Position: EXECUTIVE DIRECTOR
Credential: MACC
Phone: 334-408-4689