Healthcare Provider Details

I. General information

NPI: 1477314185
Provider Name (Legal Business Name): BHAVATI BRENNAN CPSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15120 COUNTY BARN RD
GULFPORT MS
39503-4263
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 228-213-5900
  • Fax: 222-857-5629
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number748
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: