Healthcare Provider Details

I. General information

NPI: 1265217939
Provider Name (Legal Business Name): JUANTARIO BADON PCMHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 ROBB ST
SUMMIT MS
39666-7053
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 769-217-2810
  • Fax:
Mailing address:
  • Phone: 601-705-1901
  • Fax: 601-705-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6025
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: