Healthcare Provider Details

I. General information

NPI: 1922344068
Provider Name (Legal Business Name): DELTA COMMUNITY MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1654 E UNION ST
GREENVILLE MS
38703-3250
US

IV. Provider business mailing address

1654 E UNION ST
GREENVILLE MS
38703-3250
US

V. Phone/Fax

Practice location:
  • Phone: 662-347-5183
  • Fax:
Mailing address:
  • Phone: 662-347-5183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DOTTIE CALLOWAY
Title or Position: BILLING/IT DIRECTOR
Credential:
Phone: 662-822-2219