Healthcare Provider Details

I. General information

NPI: 1306587969
Provider Name (Legal Business Name): ABIGAIL DOUGLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 COLLEGE DR
HATTIESBURG MS
39406-0002
US

IV. Provider business mailing address

202 SOUTHAMPTON RD
HATTIESBURG MS
39401-7069
US

V. Phone/Fax

Practice location:
  • Phone: 601-266-1000
  • Fax:
Mailing address:
  • Phone: 504-296-5514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: