MEDICARE: POSITIVE PATHWAYS BEHAVIORAL HEALTH: TREATMENT AND RECOVERY, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	324500000X	Substance Abuse Rehabilitation Facility

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	:	1962163287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POSITIVE PATHWAYS BEHAVIORAL HEALTH: TREATMENT AND RECOVERY, LLC

Provider Business Mailing Address
First Line	:	240 JOHNSTONE DR
Second Line	:
City	:	MADISON
State	:	MS
Zip	:	39110-7687
Country	:	US
Telephone Number	:	601-813-5878
Fax Number	:	601-738-5083

Provider Business Practice Location Address
First Line	:	345 EDGEWOOD TERRACE DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-6217
Country	:	US
Telephone Number	:	601-738-5820
Fax Number	:	601-738-5083

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TIMEKA SHE'REE WRIGHT
Credential	:	LPC
Telephone Number	:	601-738-5820

Provider Enumeration Date	:	01/08/2022
Last Update Date	:	04/28/2024

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