=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487984407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGION IV MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2010
-----------------------------------------------------
Last Update Date | 11/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301C EAST CHAMBERS DR
-----------------------------------------------------
City | BOONEVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38829-8903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-720-4816
-----------------------------------------------------
Fax | 662-720-4832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 839
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38835-0839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-720-4816
-----------------------------------------------------
Fax | 662-720-4832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUITIVE DIRECTOR
-----------------------------------------------------
Name | MR. CHARLIE SPEARMAN SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-720-4816
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------