Healthcare Provider Details

I. General information

NPI: 1477249787
Provider Name (Legal Business Name): REAGAN OWEN P-LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 AVIGNON DR STE C&D
RIDGELAND MS
39157-5120
US

IV. Provider business mailing address

745 AVIGNON DR STE C&D
RIDGELAND MS
39157-5120
US

V. Phone/Fax

Practice location:
  • Phone: 601-850-7047
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP-0920
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: