Healthcare Provider Details

I. General information

NPI: 1235523549
Provider Name (Legal Business Name): CHANDA M RHODES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CEDARWOOD DR
JACKSON MS
39212-2208
US

IV. Provider business mailing address

125 CEDARWOOD DR
JACKSON MS
39212-2208
US

V. Phone/Fax

Practice location:
  • Phone: 601-503-4563
  • Fax:
Mailing address:
  • Phone: 601-503-4563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: