=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790139087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CSTONE GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2016
-----------------------------------------------------
Last Update Date | 04/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 PINEHILLS DR
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39402-3314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-255-7200
-----------------------------------------------------
Fax | 601-255-7200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 PINEHILLS DR
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-255-7200
-----------------------------------------------------
Fax | 601-255-7200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MATTHEW WADE WICHT
-----------------------------------------------------
Credential | LPC, NCC, CEAP
-----------------------------------------------------
Telephone | 601-255-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 1035
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1035
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------