MEDICARE: MISSISSIPPI STATE UNIVERSITY

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1588491823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSISSIPPI STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	1000 HIGHWAY 19 N
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39307-5771
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 5TH ST FL 3
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39301-5108
Country	:	US
Telephone Number	:	601-484-0207
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL BILLING SPECIALIST
Name	:	KAY BOREN
Credential	:
Telephone Number	:	601-484-0207

Provider Enumeration Date	:	09/19/2024
Last Update Date	:	05/15/2026

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Directions to “MISSISSIPPI STATE UNIVERSITY ” Practice Location

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