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General NPI Number Information
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NPI Number | 1255783056
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Entity Type | Individual
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Provider Name | BROOKLEE LIGHTSEY TYNES M.A.
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Gender | Female
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Dates
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Enumeration Date | 07/06/2016
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Last Update Date | 07/29/2025
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Provider Practice Location Address
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Address Line | 102 MEDICAL PARK STE B
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City | HATTIESBURG
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State | MS
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Zip | 39401-9080
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Country | US
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Telephone | 601-261-1650
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Fax |
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Provider Business Mailing Address
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Address Line | 143 DOVE HOLW
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City | PETAL
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State | MS
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Zip | 39465-7800
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Country | US
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Telephone | 601-543-3008
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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 | 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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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 631171
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 631171
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License Number State | MS
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