=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609327329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE MENTAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2016
-----------------------------------------------------
Last Update Date | 10/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2104 CROSSBRIDGE BLVD
-----------------------------------------------------
City | BYRAM
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39272-8716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-487-8630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2104 CROSSBRIDGE BLVD
-----------------------------------------------------
City | BYRAM
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39272-8716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-487-8630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | TERESA HAMMAKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-942-1148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | R875679
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------