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General NPI Number Information
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NPI Number | 1134962525
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Entity Type | Organization
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Legal Business Name | BEACON BEHAVIORAL OF MISSISSIPPI, LLC
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Dates
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Enumeration Date | 06/14/2024
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Last Update Date | 07/11/2024
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Provider Practice Location Address
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Address Line | 3531 LAKELAND DR STE 1060
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City | FLOWOOD
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State | MS
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Zip | 39232-8016
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Country | US
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Telephone | 301-420-5810
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Fax | 601-420-5811
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Provider Business Mailing Address
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Address Line | PO BOX 306600
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City | NASHVILLE
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State | TN
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Zip | 37230-6600
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Country | US
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Telephone | 601-420-5810
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Fax | 601-420-5811
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Authorized Official
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Title or Position | CREDENTIALING SUPERVISOR
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Name | KIMBERLY GLAVESKAS
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Credential |
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Telephone | 443-962-3945
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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