=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427968338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA S ULLRICH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2026
-----------------------------------------------------
Last Update Date | 09/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 GOODMAN RD W STE 305
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-8004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-865-9563
-----------------------------------------------------
Fax | 662-510-8053
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4517 PLEASANT BREEZE DR
-----------------------------------------------------
City | OLIVE BRANCH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38654-0018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-880-8530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | P-1632
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------