Healthcare Provider Details

I. General information

NPI: 1225807555
Provider Name (Legal Business Name): MS COUNSELING AND PSYCHIATRIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2023
Last Update Date: 12/28/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1893 CLIFF GOOKIN BLVD STE B
TUPELO MS
38801-6558
US

IV. Provider business mailing address

1893 CLIFF GOOKIN BLVD STE B
TUPELO MS
38801-6558
US

V. Phone/Fax

Practice location:
  • Phone: 662-346-4584
  • Fax: 662-346-4589
Mailing address:
  • Phone: 662-346-4584
  • Fax: 662-346-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SCOTT WAGNER
Title or Position: PRESIDENT
Credential:
Phone: 662-322-6259