Healthcare Provider Details

I. General information

NPI: 1689446346
Provider Name (Legal Business Name): MEQUANDRA TWILLIE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
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: 601-649-7921
  • Fax: 601-649-7939
Mailing address:
  • Phone: 601-705-1901
  • Fax: 601-705-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM10702
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: