Healthcare Provider Details

I. General information

NPI: 1770908147
Provider Name (Legal Business Name): MAMIE SWIMS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

983 S LINE ST
GRENADA MS
38901-3723
US

IV. Provider business mailing address

983 S LINE ST
GRENADA MS
38901-3723
US

V. Phone/Fax

Practice location:
  • Phone: 662-809-3794
  • Fax: 662-226-3794
Mailing address:
  • Phone: 662-809-3794
  • Fax: 662-226-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC6400
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: