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General NPI Number Information
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NPI Number | 1750051173
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Entity Type | Organization
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Legal Business Name | DESOTO WELLNESS CLINIC LLC
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Dates
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Enumeration Date | 09/16/2021
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Last Update Date | 09/16/2021
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Provider Practice Location Address
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Address Line | 8829 CENTRE ST STE 100
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City | SOUTHAVEN
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State | MS
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Zip | 38671-2610
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Country | US
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Telephone | 662-934-8671
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Fax |
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Provider Business Mailing Address
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Address Line | 222 SOUTHLAKES DR
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City | GRENADA
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State | MS
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Zip | 38901-8499
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Country | US
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Telephone | 662-934-8671
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. CEDRIC EDWARDS
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Credential | MD
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Telephone | 662-934-8671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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