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General NPI Number Information
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NPI Number | 1487065587
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Entity Type | Organization
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Legal Business Name | BEHAVIORAL HEALTH AND WELLNESS
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Dates
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Enumeration Date | 05/13/2014
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Last Update Date | 05/13/2014
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Provider Practice Location Address
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Address Line | 4805 POPLAR SPRINGS DR SUITE A
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City | MERIDIAN
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State | MS
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Zip | 39305-2625
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Country | US
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Telephone | 601-693-1234
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Fax |
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Provider Business Mailing Address
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Address Line | 4805 POPLAR SPRINGS DR SUITE A
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City | MERIDIAN
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State | MS
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Zip | 39305-2625
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Country | US
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Telephone | 601-693-1234
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RICARDO FRAGA
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Credential | LPC
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Telephone | 601-693-1234
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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 | MCLPC1329
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License Number State | MS
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