=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730661331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIR PARK COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2018
-----------------------------------------------------
Last Update Date | 11/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 E MAIN ST STE 2C
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38804-4017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-760-0052
-----------------------------------------------------
Fax | 662-495-4080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 E MAIN ST STE 2C
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38804-4017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-760-0052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. KELLY W FERGUSON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 662-760-0052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------