Healthcare Provider Details

I. General information

NPI: 1265896153
Provider Name (Legal Business Name): SONYA AYCOCK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 GRANDVIEW DR
GRENADA MS
38901-5066
US

IV. Provider business mailing address

2504 BROWNING ROAD 520
GREENWOOD MS
38930-6022
US

V. Phone/Fax

Practice location:
  • Phone: 662-227-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1822
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: