=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992419196
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACE SYNERVATIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2023
-----------------------------------------------------
Last Update Date | 08/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE STE 3140
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-251-5751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE STE 3140
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-251-5751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO-OWNER
-----------------------------------------------------
Name | LATESHA W THOMAS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 769-251-5751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------