Healthcare Provider Details

I. General information

NPI: 1124032677
Provider Name (Legal Business Name): GERALDINE BATES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SALLY BATES LCSW

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 E CAPITOL ST 840 TRUST MARK BLDG
JACKSON MS
39201-2503
US

IV. Provider business mailing address

278 MARY MAGDALENE RD
HATTIESBURG MS
39401-8493
US

V. Phone/Fax

Practice location:
  • Phone: 800-632-6074
  • Fax:
Mailing address:
  • Phone: 601-307-5303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC0717
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: