Healthcare Provider Details

I. General information

NPI: 1629392774
Provider Name (Legal Business Name): SOUTH MISSISSIPPI REGIONAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 W RAILROAD ST
LONG BEACH MS
39560-4106
US

IV. Provider business mailing address

1170 W RAILROAD ST
LONG BEACH MS
39560-4106
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-1348
  • Fax: 228-214-5563
Mailing address:
  • Phone: 228-867-1348
  • Fax: 228-214-5563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number311
License Number StateMS

VIII. Authorized Official

Name: MRS. JOANNA WHALEY
Title or Position: BENEFIT SPECIALIST
Credential:
Phone: 228-867-1348