Healthcare Provider Details

I. General information

NPI: 1740145911
Provider Name (Legal Business Name): LARUBY REDDICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 DESOTO AVE STE 109
CLARKSDALE MS
38614-4440
US

IV. Provider business mailing address

1867 CRANE RIDGE DR STE 150C
JACKSON MS
39216-4982
US

V. Phone/Fax

Practice location:
  • Phone: 662-592-5397
  • Fax:
Mailing address:
  • Phone: 662-592-5397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: