MEDICARE: TRIPLE H RANCH 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1619684461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIPLE H RANCH LLC

Provider Business Mailing Address
First Line	:	7205 HUMPHREY RD
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565-7806
Country	:	US
Telephone Number	:	228-283-5005
Fax Number	:

Provider Business Practice Location Address
First Line	:	7205 HUMPHREY RD
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565-7806
Country	:	US
Telephone Number	:	228-283-5005
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	MRS. DAWN VANBUSKIRK
Credential	:	LCSW
Telephone Number	:	228-283-5005

Provider Enumeration Date	:	11/01/2022
Last Update Date	:	11/01/2022

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Directions to “TRIPLE H RANCH LLC ” Practice Location

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