Healthcare Provider Details

I. General information

NPI: 1518747567
Provider Name (Legal Business Name): MISSISSIPPI STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2023
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 FAMOUS MAROON BAND STREET
MISSISSIPPI STATE MS
39762
US

IV. Provider business mailing address

PO BOX 6124
MISSISSIPPI STATE MS
39762-6124
US

V. Phone/Fax

Practice location:
  • Phone: 662-325-0621
  • Fax: 662-325-0895
Mailing address:
  • Phone: 662-325-0621
  • Fax: 662-325-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DANIEL TODD HALE
Title or Position: DIRECTOR, FISCAL OPERATIONS, STUDEN
Credential:
Phone: 662-325-5895