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General NPI Number Information
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NPI Number | 1114469640
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Entity Type | Organization
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Legal Business Name | DESOTO FAMILYCOUNSELING CENTER
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Dates
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Enumeration Date | 11/15/2016
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Last Update Date | 11/15/2016
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Provider Practice Location Address
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Address Line | 6858 SWINNEA RD BUILDING 4
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9493
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Country | US
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Telephone | 662-772-5937
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Fax | 662-772-5940
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Provider Business Mailing Address
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Address Line | 6858 SWINNEA RD BUILDING 4
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9493
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Country | US
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Telephone | 662-772-5937
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Fax | 662-772-5940
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | AMANDA C WOOD
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Credential |
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Telephone | 662-772-5937
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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