=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013374347
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARRIE VIRGINIA PATE THERAPY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2016
-----------------------------------------------------
Last Update Date | 05/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2112 BIENVILLE BLVD SUITE L-1
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-990-8980
-----------------------------------------------------
Fax | 228-215-1721
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2112 BIENVILLE BLVD SUITE L-1
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-215-1744
-----------------------------------------------------
Fax | 228-215-1721
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND PRACTITIONER
-----------------------------------------------------
Name | MS. CARRIE V PATE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 228-990-8980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C6890
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------