Healthcare Provider Details

I. General information

NPI: 1134501364
Provider Name (Legal Business Name): MISSISSIPPI BEHAVIOR SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5847 GETWELL RD STE 4
SOUTHAVEN MS
38672-6816
US

IV. Provider business mailing address

562 OLE DAN RD
SOUTHAVEN MS
38672-6200
US

V. Phone/Fax

Practice location:
  • Phone: 662-470-6160
  • Fax:
Mailing address:
  • Phone: 901-216-1486
  • Fax: 662-470-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. VARGAS L CLARK
Title or Position: CEO
Credential: BCBA
Phone: 901-216-1486