Healthcare Provider Details

I. General information

NPI: 1942327515
Provider Name (Legal Business Name): DELTA COMMUNITY MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 W RACE ST
ROLLING FORK MS
39159-2623
US

IV. Provider business mailing address

317 W RACE ST
ROLLING FORK MS
39159-2623
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-6228
  • Fax: 662-873-2244
Mailing address:
  • Phone: 662-873-6228
  • Fax: 662-873-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16335
License Number StateMS

VIII. Authorized Official

Name: DR. GILBERT MACVAUGH
Title or Position: EXECUTIVE DIRECTOR
Credential: PSY
Phone: 662-335-5274