Healthcare Provider Details

I. General information

NPI: 1063754083
Provider Name (Legal Business Name): MIDSOUTH THERAPY SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 MCINGVALE RD
HERNANDO MS
38632-8795
US

IV. Provider business mailing address

3130 MCINGVALE RD
HERNANDO MS
38632-8795
US

V. Phone/Fax

Practice location:
  • Phone: 662-469-9009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHARLETTE MCBRIDE
Title or Position: CEO
Credential:
Phone: 662-469-9009