Healthcare Provider Details

I. General information

NPI: 1770348153
Provider Name (Legal Business Name): WALTHALL COUNTY BEHAVIORAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/24/2024
Certification Date: 02/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 OLD STATE LINE RD
TYLERTOWN MS
39667-5020
US

IV. Provider business mailing address

125 OLD STATE LINE RD
TYLERTOWN MS
39667-5020
US

V. Phone/Fax

Practice location:
  • Phone: 601-303-0472
  • Fax:
Mailing address:
  • Phone: 601-303-0472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: SYLVIA STOGNER
Title or Position: PRESIDENT/OWNER
Credential: LCSW
Phone: 601-303-0472