Healthcare Provider Details

I. General information

NPI: 1497419428
Provider Name (Legal Business Name): TYRA ROWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 MEMPHIS ST STE 206
HERNANDO MS
38632-1757
US

IV. Provider business mailing address

PO BOX 675
NESBIT MS
38651-0675
US

V. Phone/Fax

Practice location:
  • Phone: 662-268-7594
  • Fax: 662-391-4209
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3032
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: