Healthcare Provider Details

I. General information

NPI: 1265156533
Provider Name (Legal Business Name): MARILYN SMITH CIDDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5192 HIGHWAY 11 N
ELLISVILLE MS
39437-5050
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-3439
  • Fax: 601-649-7939
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number588
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: