=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417797945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESIREE DAWN WYROSDICK SIMMONS CMHT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2024
-----------------------------------------------------
Last Update Date | 05/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 ADELINE ST STE B
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-243-5124
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1980 PURVIS BAXTERVILLE RD
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39455-8932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-314-5060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------