Healthcare Provider Details

I. General information

NPI: 1740643246
Provider Name (Legal Business Name): JOHNNA CARTER CMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOHNNA BUSH CMHT

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 DEWEY ST
COLUMBIA MS
39429-2751
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 601-736-6799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3102
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: