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General NPI Number Information
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NPI Number | 1700648631
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Entity Type | Organization
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Legal Business Name | MAINKA TELETHERAPY SERVICES, LLC
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Dates
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Enumeration Date | 01/25/2024
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Last Update Date | 01/25/2024
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Provider Practice Location Address
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Address Line | 1210 POLK ST
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City | VICKSBURG
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State | MS
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Zip | 39180-5024
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Country | US
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Telephone | 601-456-2633
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Fax |
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Provider Business Mailing Address
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Address Line | 665 S PEAR ORCHARD RD STE 106-701
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City | RIDGELAND
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State | MS
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Zip | 39157-4861
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Country | US
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Telephone | 601-456-2633
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ALICIA MAINKA
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Credential | LPC, LMFT
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Telephone | 601-456-2633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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