Healthcare Provider Details

I. General information

NPI: 1962012468
Provider Name (Legal Business Name): DEBRA DIANN WUICHET LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2020
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S SPRING ST
TUPELO MS
38804-4853
US

IV. Provider business mailing address

503 MAURY CIR
TUPELO MS
38801-4109
US

V. Phone/Fax

Practice location:
  • Phone: 662-205-0098
  • Fax: 662-495-4079
Mailing address:
  • Phone: 662-231-0310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number261QR0405X
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: