Healthcare Provider Details

I. General information

NPI: 1821827155
Provider Name (Legal Business Name): CHASE HOUSE OF YOUTH RESTORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

394 W OXFORD ST
PONTOTOC MS
38863-1219
US

IV. Provider business mailing address

394 W OXFORD ST
PONTOTOC MS
38863-1219
US

V. Phone/Fax

Practice location:
  • Phone: 662-586-8081
  • Fax:
Mailing address:
  • Phone: 662-586-8081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MASON TODD HESTER
Title or Position: DIRECTOR
Credential:
Phone: 662-586-8081