MEDICARE: PSYCAMORE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1285722678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCAMORE, LLC

Provider Business Mailing Address
First Line	:	2540 FLOWOOD DR
Second Line	:
City	:	FLOWOOD
State	:	MS
Zip	:	39232-9362
Country	:	US
Telephone Number	:	601-939-5993
Fax Number	:	601-939-5935

Provider Business Practice Location Address
First Line	:	2540 FLOWOOD DR
Second Line	:
City	:	FLOWOOD
State	:	MS
Zip	:	39232-9362
Country	:	US
Telephone Number	:	601-939-5993
Fax Number	:	601-939-5935

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MS. KIMBERLY MADAKASIRA
Credential	:	LPC
Telephone Number	:	601-939-5993

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	08/22/2020

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