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Organization
SW MS MENTAL HEALTH MENTAL RETARDATION COMMISSION
Active
Organization
SW MS MENTAL HEALTH MENTAL RETARDATION COMMISSION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MONTAVIA DORSEY (CREDENTIALING MGR)
(601) 249-4235
Entity
Organization
Contact information
Practice address
1701 WHITE ST, MCCOMB, MS 39648
(601) 684-2173
(601) 249-4234
Mailing address
PO BOX 768, 1701 WHITE ST, MCCOMB, MS 39649
(601) 684-2173
(601) 249-4234
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00018211
—
MS
Enumeration date
06/04/2006
Last updated
04/06/2023
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