Healthcare Provider Details

I. General information

NPI: 1891003331
Provider Name (Legal Business Name): GERALYN DATZ PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 COURT ST
HATTIESBURG MS
39401-3944
US

IV. Provider business mailing address

502 COURT ST
HATTIESBURG MS
39401-3944
US

V. Phone/Fax

Practice location:
  • Phone: 601-434-9402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. GERALYN DATZ
Title or Position: OWNER
Credential: PHD
Phone: 601-434-9402