=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477346310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATRICE FOX DILLARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2025
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6920 OAK FOREST DR
-----------------------------------------------------
City | OLIVE BRANCH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38654-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-892-2660
-----------------------------------------------------
Fax | 662-200-5842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2430 JOHNNY WALKER RD
-----------------------------------------------------
City | POTTS CAMP
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38659-9310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-688-5848
-----------------------------------------------------
Fax | 662-688-5848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | M10447
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------