Healthcare Provider Details

I. General information

NPI: 1346992294
Provider Name (Legal Business Name): HAVEN E OVERSTREET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 SAINT ANNES DR
HATTIESBURG MS
39401-8252
US

IV. Provider business mailing address

4229 U S HIGHWAY 11
HATTIESBURG MS
39402-8024
US

V. Phone/Fax

Practice location:
  • Phone: 601-447-4658
  • Fax:
Mailing address:
  • Phone: 601-447-4658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number21-192155
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: