Healthcare Provider Details

I. General information

NPI: 1053050591
Provider Name (Legal Business Name): DEFINING WELLNESS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 HANOVER CIR STE 100
RIDGELAND MS
39157-8814
US

IV. Provider business mailing address

3949 HIGHWAY 43 N
BRANDON MS
39047-7240
US

V. Phone/Fax

Practice location:
  • Phone: 855-761-1582
  • Fax: 769-241-2605
Mailing address:
  • Phone: 754-261-8405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SONYA MUKHERJEE
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 754-261-8405