Healthcare Provider Details

I. General information

NPI: 1154904035
Provider Name (Legal Business Name): VITALITY COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 KEY DR STE C
MADISON MS
39110-7378
US

IV. Provider business mailing address

1888 MAIN ST STE C-419
MADISON MS
39110-6337
US

V. Phone/Fax

Practice location:
  • Phone: 601-760-2050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional 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: CRAIG WATSON
Title or Position: CEO
Credential: LPC
Phone: 601-760-2050