Healthcare Provider Details

I. General information

NPI: 1083733182
Provider Name (Legal Business Name): MICHAEL K TRAYLOR L.M.F.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 N STATE ST
JACKSON MS
39201-1108
US

IV. Provider business mailing address

7068 EDGEWATER DR
RIDGELAND MS
39157-1011
US

V. Phone/Fax

Practice location:
  • Phone: 601-949-1949
  • Fax:
Mailing address:
  • Phone: 601-949-1949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberTO349
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: