=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386356806
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDEN TRIANGLE HEALING PLACE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2022
-----------------------------------------------------
Last Update Date | 04/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1014 N JACKSON ST
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-435-0670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2345 HIGHWAY 47
-----------------------------------------------------
City | WEST POINT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39773-4158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-430-1513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JANAE ERIN ROBINSON
-----------------------------------------------------
Credential | MS, LPC-S, NCC
-----------------------------------------------------
Telephone | 662-435-0670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------