Healthcare Provider Details

I. General information

NPI: 1689389397
Provider Name (Legal Business Name): SHAUNITA WEATHERSBY CMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91180 HIGHWAY 42
RICHTON MS
39476-9254
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 601-788-6308
  • Fax: 601-788-6349
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5600
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: