MEDICARE: PLAY FABULOUS

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	251S00000X	Community/Behavioral Health Agency	1239	MS

General Provider Information

NPI Number	:	1598129090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLAY FABULOUS

Provider Business Mailing Address
First Line	:	9761 DOROTHY DR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-6598
Country	:	US
Telephone Number	:	901-412-2720
Fax Number	:

Provider Business Practice Location Address
First Line	:	9761 DOROTHY DR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-6598
Country	:	US
Telephone Number	:	901-412-2720
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR
Name	:	MRS. STACEY DENISE GUTHRIE-ALDINGER
Credential	:	ED.S, LPC-S,RPT, NCC
Telephone Number	:	901-412-2720

Provider Enumeration Date	:	04/11/2016
Last Update Date	:	04/11/2016

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