=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568558161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN MS PLANNING AND DEVELOPMENT DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9229 HWY 49
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-868-2311
-----------------------------------------------------
Fax | 228-868-2550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9229 HWY 49
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-868-2311
-----------------------------------------------------
Fax | 228-863-2550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAID WAIVER SUPERVISOR
-----------------------------------------------------
Name | DOROTHY WALLEY
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 228-314-1475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------