Healthcare Provider Details

I. General information

NPI: 1316290067
Provider Name (Legal Business Name): ANDRES G VIANA PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPT OF PSYCHIATRY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5855
  • Fax: 601-984-5857
Mailing address:
  • Phone: 601-984-5855
  • Fax: 601-984-5857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number52908
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: