Healthcare Provider Details

I. General information

NPI: 1073153656
Provider Name (Legal Business Name): KADESHIA HUNT PCMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 08/31/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 N. MAIN STREET
FAYETTE MS
39069
US

IV. Provider business mailing address

3444 WISCONSIN AVE
VICKSBURG MS
39180-5331
US

V. Phone/Fax

Practice location:
  • Phone: 601-786-8091
  • Fax: 601-786-8023
Mailing address:
  • Phone: 601-638-0031
  • Fax: 601-638-1778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: