Healthcare Provider Details

I. General information

NPI: 1710175260
Provider Name (Legal Business Name): CLINICAL NEUROSCIENCE GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3531 LAKELAND DR SUITE 1058
FLOWOOD MS
39232-8049
US

IV. Provider business mailing address

3531 LAKELAND DR SUITE 1058
FLOWOOD MS
39232-8049
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-7010
  • Fax:
Mailing address:
  • Phone: 601-420-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN ELGIN WILKAITIS
Title or Position: PRESIDENT
Credential: M.D., M.S.
Phone: 601-420-7010