Healthcare Provider Details

I. General information

NPI: 1013922954
Provider Name (Legal Business Name): SPECIALIZED TREATMENT FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14426 JAMES BOND RD
GULFPORT MS
39503-8311
US

IV. Provider business mailing address

14426 JAMES BOND RD
GULFPORT MS
39503-8311
US

V. Phone/Fax

Practice location:
  • Phone: 228-328-6000
  • Fax: 228-328-6035
Mailing address:
  • Phone: 228-328-6000
  • Fax: 228-328-6035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number981
License Number StateMS

VIII. Authorized Official

Name: MRS. SHANNON Y BUSH
Title or Position: PROGRAM DIRECTOR
Credential: MPA
Phone: 228-328-6000