Healthcare Provider Details

I. General information

NPI: 1558035055
Provider Name (Legal Business Name): PANTHER CREEK FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 CONGER RD
NESBIT MS
38651-8898
US

IV. Provider business mailing address

2531 SHILLINGFORD DR
MEMPHIS TN
38119-7820
US

V. Phone/Fax

Practice location:
  • Phone: 662-912-5440
  • Fax:
Mailing address:
  • Phone: 901-574-1740
  • 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 Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MYLISSA HORROCKS
Title or Position: EXECUTIVE DIRECTOR
Credential: MPH
Phone: 901-574-1740