Healthcare Provider Details

I. General information

NPI: 1508804626
Provider Name (Legal Business Name): MARY CECILLE GOYSICH PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4579 S EASON BLVD
TUPELO MS
38801-6539
US

IV. Provider business mailing address

450 E PRESIDENT AVE
TUPELO MS
38801-5599
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3161
  • Fax: 662-377-2993
Mailing address:
  • Phone: 662-377-4685
  • Fax: 662-377-2755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number33538
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: