Healthcare Provider Details

I. General information

NPI: 1003195967
Provider Name (Legal Business Name): PSYCAMORE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 EXECUTIVE PL
BILOXI MS
39531-3717
US

IV. Provider business mailing address

2620 EXECUTIVE PL
BILOXI MS
39531-3717
US

V. Phone/Fax

Practice location:
  • Phone: 228-385-7744
  • Fax: 601-939-5935
Mailing address:
  • Phone: 601-939-5993
  • Fax: 601-939-5935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberDCS-PSYCAMORE-PHA-01
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberDCS-PSYCAMORE-PHA-01
License Number StateMS

VIII. Authorized Official

Name: KATHERINE A HALL
Title or Position: DIRECTOR, BUSINESS OPERATIONS
Credential: CMM
Phone: 601-939-5993