Healthcare Provider Details

I. General information

NPI: 1902395577
Provider Name (Legal Business Name): REBECCA BLOUNT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520A W CANAL ST
PICAYUNE MS
39466-3915
US

IV. Provider business mailing address

520A W CANAL ST
PICAYUNE MS
39466-3915
US

V. Phone/Fax

Practice location:
  • Phone: 601-599-9500
  • Fax:
Mailing address:
  • Phone: 769-926-2511
  • Fax: 769-926-2509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: REBECCA G. BLOUNT
Title or Position: OWNER
Credential: PMHNP
Phone: 601-569-1567