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General NPI Number Information
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NPI Number | 1437763240
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Entity Type | Organization
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Legal Business Name | STARKVILLE WELLNESS GROUP
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Dates
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Enumeration Date | 08/31/2020
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Last Update Date | 06/29/2022
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Provider Practice Location Address
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Address Line | 100 STARR AVE #K
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City | STARKVILLE
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State | MS
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Zip | 39759
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Country | US
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Telephone | 972-898-2394
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Fax |
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Provider Business Mailing Address
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Address Line | 100 STARR AVE #K
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City | STARKVILLE
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State | MS
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Zip | 39759
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Country | US
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Telephone | 972-898-2394
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Fax |
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Authorized Official
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Title or Position | LPC, OWNER
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Name | MRS. MARY ELIZABETH KETCHUM
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Credential | LPC
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Telephone | 662-425-1051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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