Healthcare Provider Details

I. General information

NPI: 1427968338
Provider Name (Legal Business Name): LAURA S ULLRICH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 GOODMAN RD W STE 305
SOUTHAVEN MS
38671-8004
US

IV. Provider business mailing address

4517 PLEASANT BREEZE DR
OLIVE BRANCH MS
38654-0018
US

V. Phone/Fax

Practice location:
  • Phone: 662-865-9563
  • Fax: 662-510-8053
Mailing address:
  • Phone: 662-880-8530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP-1632
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: