=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326069964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAGCVHCS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 VETERANS AVE
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39531-2410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-523-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7125 RICHMOND DR
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39532-4045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-392-8439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIST/ACTING DIRECTOR
-----------------------------------------------------
Name | DR. WILLIAM L CLAYTON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 228-523-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 5595
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------