Healthcare Provider Details

I. General information

NPI: 1295459295
Provider Name (Legal Business Name): VICTORIA GAYLENE ABBOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 HIGHWAY 51 S
HERNANDO MS
38632-2634
US

IV. Provider business mailing address

6485 BENTLEY CV
HORN LAKE MS
38637-7322
US

V. Phone/Fax

Practice location:
  • Phone: 662-449-1971
  • Fax:
Mailing address:
  • Phone: 901-581-0050
  • 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: