Healthcare Provider Details

I. General information

NPI: 1306085253
Provider Name (Legal Business Name): FULIVIA ELMA CANNADY MSCP,NCC,LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FULIVIA ELMA BANKS MSCP,NCC,LPC

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113B WILLOW BROOK DR
CLINTON MS
39056-5802
US

IV. Provider business mailing address

113B WILLOW BROOK DR
CLINTON MS
39056-5802
US

V. Phone/Fax

Practice location:
  • Phone: 601-832-8264
  • Fax:
Mailing address:
  • Phone: 601-832-8264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number208894
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1220
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: