Healthcare Provider Details

I. General information

NPI: 1700701547
Provider Name (Legal Business Name): HERMAN ISLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 ABBAY ST APT C2
TUNICA MS
38676-9324
US

IV. Provider business mailing address

1017 ABBAY ST APT C2
TUNICA MS
38676-9324
US

V. Phone/Fax

Practice location:
  • Phone: 662-613-9199
  • Fax:
Mailing address:
  • Phone: 662-613-9199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: