Healthcare Provider Details

I. General information

NPI: 1811518343
Provider Name (Legal Business Name): DANELLE WOODS PCMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BROAD AVE
GULFPORT MS
39501-3603
US

IV. Provider business mailing address

PO BOX 6705
GULFPORT MS
39506-6705
US

V. Phone/Fax

Practice location:
  • Phone: 228-863-1132
  • Fax:
Mailing address:
  • Phone: 228-865-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPH4892
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: