Healthcare Provider Details

I. General information

NPI: 1699556068
Provider Name (Legal Business Name): ROSE MARY FAVRE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 10/11/2023
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 KATHERINE DR STE A
FLOWOOD MS
39232-9588
US

IV. Provider business mailing address

505 DEMONTLUZIN AVE
BAY ST LOUIS MS
39520-3505
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4162
  • Fax: 855-830-3484
Mailing address:
  • Phone: 228-304-0446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7379
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: