Healthcare Provider Details

I. General information

NPI: 1639335938
Provider Name (Legal Business Name): PETRO PALYKHATA MA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

IV. Provider business mailing address

166 THIRD AVE
SALTILLO MS
38866-9153
US

V. Phone/Fax

Practice location:
  • Phone: 662-844-1717
  • Fax: 662-680-5129
Mailing address:
  • Phone: 662-891-6360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1353
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: