Healthcare Provider Details

I. General information

NPI: 1831321124
Provider Name (Legal Business Name): LINELL HENDERSON CMHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 MAMIE ST
HATTIESBURG MS
39402-1735
US

IV. Provider business mailing address

4100 MAMIE ST
HATTIESBURG MS
39402
US

V. Phone/Fax

Practice location:
  • Phone: 601-705-1901
  • Fax:
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0219
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: