Healthcare Provider Details

I. General information

NPI: 1801340799
Provider Name (Legal Business Name): PROVIDENCE BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5266 OLD HIGHWAY 11 STE 50
HATTIESBURG MS
39402-7818
US

IV. Provider business mailing address

5737 OLD NATIONAL HWY STE 300
ATLANTA GA
30349-3865
US

V. Phone/Fax

Practice location:
  • Phone: 678-834-7615
  • Fax:
Mailing address:
  • Phone: 678-834-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. NIKKI KWONA WRIGHT
Title or Position: DIRECTOR
Credential: MS
Phone: 678-834-7615