Healthcare Provider Details

I. General information

NPI: 1003136672
Provider Name (Legal Business Name): BRETT TYLER DILLARD B.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 LAFAYETTE ST
PONTOTOC MS
38863-2837
US

IV. Provider business mailing address

39 LAFAYETTE ST
PONTOTOC MS
38863-2837
US

V. Phone/Fax

Practice location:
  • Phone: 662-509-6759
  • Fax: 662-509-6761
Mailing address:
  • Phone: 662-509-9300
  • Fax: 662-509-6698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: