Healthcare Provider Details

I. General information

NPI: 1972616076
Provider Name (Legal Business Name): GERALYN DATZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COMMERCE DR STE 205
HATTIESBURG MS
39402-1499
US

IV. Provider business mailing address

PO BOX 1614
HATTIESBURG MS
39403-1614
US

V. Phone/Fax

Practice location:
  • Phone: 601-255-1618
  • Fax: 601-255-1619
Mailing address:
  • Phone: 601-255-1618
  • Fax: 601-255-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number45736
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number45-736
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1140
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number1140
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: