Healthcare Provider Details

I. General information

NPI: 1801828496
Provider Name (Legal Business Name): NORTHEAST MENTAL HEALTH/MENTAL RETARDATION COMMISSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

IV. Provider business mailing address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

V. Phone/Fax

Practice location:
  • Phone: 662-640-4695
  • Fax: 662-680-6416
Mailing address:
  • Phone: 662-640-4595
  • Fax: 662-680-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. RAQUEL ROSAMOND
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 662-640-4595