Healthcare Provider Details

I. General information

NPI: 1265249288
Provider Name (Legal Business Name): RETA COZETTE CHANDLER LPC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 MCLAURIN ST
MADISON MS
39110-8613
US

IV. Provider business mailing address

505 MCLAURIN ST
MADISON MS
39110-8613
US

V. Phone/Fax

Practice location:
  • Phone: 601-291-9521
  • Fax:
Mailing address:
  • Phone: 601-291-9521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1771
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: