Healthcare Provider Details

I. General information

NPI: 1730869892
Provider Name (Legal Business Name): FAMILY COACHING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 EXECUTIVE DR STE B
MADISON MS
39110-8496
US

IV. Provider business mailing address

52 REDBUD LN
MADISON MS
39110-9261
US

V. Phone/Fax

Practice location:
  • Phone: 601-506-2292
  • Fax:
Mailing address:
  • Phone: 601-506-2292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JOHN WEBB
Title or Position: DIRECTOR
Credential: LPC-S
Phone: 601-506-2292