=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841778545
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DINAH MARIE BUFKIN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2018
-----------------------------------------------------
Last Update Date | 08/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1640 LELIA DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-790-1734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 GRANBERRY WAY
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39110-8534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-383-4849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2295
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------