=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396549697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY RAE DE VITO LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2025
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8626 AIRWAYS BLVD
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-772-5937
-----------------------------------------------------
Fax | 662-772-5940
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 COUNTY ROAD 108
-----------------------------------------------------
City | WATER VALLEY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38965-3911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-341-3633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 3238
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------