=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598346041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEFINING YOU THERAPEUTIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2021
-----------------------------------------------------
Last Update Date | 11/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2941 TERRY RD STE 1
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39212-3071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-278-7137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 CANEBRAKE BLVD
-----------------------------------------------------
City | FLOWOOD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39232-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KANDACE ROSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-278-7137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------