=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598418030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORED HEALTH ASSOCIATES CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2022
-----------------------------------------------------
Last Update Date | 02/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 541 COMMERCE ST
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39440-3954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-577-2782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530 EUCUTTA RD
-----------------------------------------------------
City | HEIDELBERG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39439-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JESSICA BROWNLEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-577-2782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------