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General NPI Number Information
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NPI Number | 1396315792
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Entity Type | Organization
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Legal Business Name | SSIPP SELECT BASKETBALL & MENTORING PROGRAM NON PROFIT
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Dates
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Enumeration Date | 06/28/2021
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Last Update Date | 06/28/2021
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Provider Practice Location Address
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Address Line | 3 NOTTINGHAM CIR
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City | GULFPORT
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State | MS
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Zip | 39503-4021
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Country | US
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Telephone | 662-519-1608
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Fax |
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Provider Business Mailing Address
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Address Line | 3 NOTTINGHAM CIR
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City | GULFPORT
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State | MS
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Zip | 39503-4021
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Country | US
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Telephone | 662-519-1608
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. LEONARD C BENNETT
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Credential |
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Telephone | 662-519-1608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | 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 | 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 #3
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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