Healthcare Provider Details

I. General information

NPI: 1255024162
Provider Name (Legal Business Name): TAMILA BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMILA BROWN

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 07/22/2023
Certification Date: 07/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 GOODMAN RD E
SOUTHAVEN MS
38671-9542
US

IV. Provider business mailing address

1310 GOODMAN RD E
SOUTHAVEN MS
38671-9542
US

V. Phone/Fax

Practice location:
  • Phone: 662-470-5433
  • Fax:
Mailing address:
  • Phone: 662-470-5433
  • Fax: 662-536-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3003
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: