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General NPI Number Information
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NPI Number | 1184328890
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Entity Type | Organization
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Legal Business Name | INNOVATIVE COUNSELING OF MISSISSIPPI, PLLC
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Dates
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Enumeration Date | 03/28/2023
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Last Update Date | 04/04/2023
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Provider Practice Location Address
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Address Line | 4780 1-55 N SUITE 100-103
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City | JACKSON
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State | MS
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Zip | 39211
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Country | US
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Telephone | 601-708-9558
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Fax |
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Provider Business Mailing Address
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Address Line | 115 BELLEGROVE BLVD
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City | BRANDON
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State | MS
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Zip | 39047-6625
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SARAH MARIE PRADILLO
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Credential | LPC
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Telephone | 601-708-9558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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