MEDICARE: PHILIP MASSEY

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	104100000X	Social Worker	M7217	MS
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	AD07-046M	MS
3	390200000X	Student in an Organized Health Care Education/Training Program
4	1041C0700X	Clinical Social Worker	C7217	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306242458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP MASSEY

Provider Business Mailing Address
First Line	:	PO BOX 2305
Second Line	:
City	:	CLINTON
State	:	MS
Zip	:	39060-2305
Country	:	US
Telephone Number	:	601-272-2202
Fax Number	:	601-292-7998

Provider Business Practice Location Address
First Line	:	5345 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-927-0188
Fax Number	:	601-292-7998

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2014
Last Update Date	:	09/11/2023

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Directions to “ PHILIP MASSEY ” Practice Location

Language	Start Address	Practice Location

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