Healthcare Provider Details

I. General information

NPI: 1295827558
Provider Name (Legal Business Name): TIJUANA SIMELTON B.S., MHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 11/29/2016
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

510 BEECHWOOD CIR HOUSE #56
CORINTH MS
38834-6937
US

V. Phone/Fax

Practice location:
  • Phone: 662-640-4595
  • Fax:
Mailing address:
  • Phone: 662-750-4861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: