=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053957720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAVANNA MULLINS NORFLEET LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2019
-----------------------------------------------------
Last Update Date | 12/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4400 OLD CANTON RD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39211-5982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-984-2080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4400 OLD CANTON RD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39211-5982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-984-2080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1974
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------