Healthcare Provider Details

I. General information

NPI: 1083915656
Provider Name (Legal Business Name): ANN MILLSAPS WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 DICKERSON LN
COLUMBUS MS
39705-1648
US

IV. Provider business mailing address

455 DICKERSON LN
COLUMBUS MS
39705-1648
US

V. Phone/Fax

Practice location:
  • Phone: 662-327-1575
  • Fax:
Mailing address:
  • Phone: 662-327-1575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1398
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: