Healthcare Provider Details

I. General information

NPI: 1609598986
Provider Name (Legal Business Name): ALICE ABRAM CMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 MCMANUS ST
ELLISVILLE MS
39437-3800
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 601-792-5279
  • Fax: 601-792-8197
Mailing address:
  • Phone: 601-705-1901
  • Fax: 601-705-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3115
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: