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NPI Code Detail

MEDICARE: SOTDERIA GRIFFIN

MEDICARE: SOTDERIA GRIFFIN
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
1101YP2500XProfessional Counselor5886LA

General Provider Information

NPI Number : 1477903136
Entity Type Code : Individual
Provider Name (Legal Business Name) : SOTDERIA GRIFFIN
Provider Business Mailing Address
First Line : 879 WILLIAM BLVD APT 21C
Second Line :
City : RIDGELAND
State : MS
Zip : 39157-1571
Country : US
Telephone Number : 601-310-6900
Fax Number : 318-574-4407
Provider Business Practice Location Address
First Line : 124 KIMBROUGH BLVD BLDG Q
Second Line :
City : TALLULAH
State : LA
Zip : 71282-4307
Country : US
Telephone Number : 318-574-4400
Fax Number : 318-574-4407
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2016
Last Update Date : 06/14/2016

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Directions to “ SOTDERIA GRIFFIN ” Practice Location

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