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General NPI Number Information
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NPI Number | 1700319068
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Entity Type | Organization
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Legal Business Name | PROSPERITY COUNSELING SERVICE LLC
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Dates
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Enumeration Date | 04/04/2017
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Last Update Date | 04/04/2017
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Provider Practice Location Address
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Address Line | 2627 RIDGEWOOD RD STE 103
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City | JACKSON
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State | MS
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Zip | 39216-4904
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Country | US
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Telephone | 601-942-1884
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Fax |
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Provider Business Mailing Address
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Address Line | 252 CALLAWAY CIR
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City | BYRAM
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State | MS
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Zip | 39272-4521
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Country | US
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Telephone | 601-942-1884
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TANYA LARRY
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Credential | LMFT
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Telephone | 601-942-1884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | T0442
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License Number State | MS
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