Healthcare Provider Details

I. General information

NPI: 1871358184
Provider Name (Legal Business Name): COMMUNITY MENTAL HEALTH CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SAINT PAUL ST
PEARL MS
39208-5134
US

IV. Provider business mailing address

1393 OLD PEARSON RD
FLORENCE MS
39073-9468
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-7983
  • Fax:
Mailing address:
  • Phone: 601-665-7983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LATONYA JATON MCGOWAN
Title or Position: OWNER
Credential: NP
Phone: 601-665-7983