=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215314562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIOR SERVICES OF THE MID-SOUTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2015
-----------------------------------------------------
Last Update Date | 05/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8349 TRINITY RD
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38018-6761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-484-3545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8349 TRINITY RD
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38018-6761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-484-3545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MR. JAMES B ELSWICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-484-3545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 000219479
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------