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General NPI Number Information
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NPI Number | 1134528821
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Entity Type | Individual
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Provider Name | MARK TYNER HAGWOOD D.P.C.
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Gender | Male
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Dates
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Enumeration Date | 08/19/2014
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Last Update Date | 10/08/2014
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Provider Practice Location Address
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Address Line | 128 MAPLE DRIVE SUITE A
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City | RIDGELAND
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State | MS
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Zip | 39157
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Country | US
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Telephone | 601-863-9430
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Fax |
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Provider Business Mailing Address
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Address Line | 137 HIGHWOODS BLVD
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City | MADISON
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State | MS
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Zip | 39110-7423
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Country | US
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Telephone | 601-863-8430
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1924
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License Number State | MS
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