=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912586033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARISHAN WINDER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2021
-----------------------------------------------------
Last Update Date | 04/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 STATELINE RD W
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-1610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-510-5980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1907 TALISKER DR
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38016-0154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-910-8730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | PA00335
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------