# DESOTO FAMILY WELLNESS CENTER, LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376143024
- **Authorized official:** AMY LYNN OLLAR (OFFICE MANAGER)
- **Authorized official phone:** (662) 892-2885

## Contact information

- **Practice address:** 3495 COBBLESTONE BLVD S, SOUTHAVEN, MS 38672-7075
- **Practice address phone:** (662) 892-2885
- **Practice address fax:** (662) 892-2889
- **Mailing address:** 3495 COBBLESTONE BLVD S, SOUTHAVEN, MS 38672-7075
- **Mailing address phone:** (662) 892-2885
- **Mailing address fax:** (662) 892-2889

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YP2500X | Professional Counselor | — | NULL | — |
| 101YP2500X | Professional Counselor | — | — | — |
| 103TC1900X | Counseling Psychologist | — | NULL | — |
| 103TC1900X | Counseling Psychologist | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 261QM0801X | Mental Health Clinic/Center (Including Community Mental Health Center) | — | NULL | — |
| 261QM1300X | Multi-Specialty Clinic/Center | — | NULL | Yes |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |
| 363LP2300X | Primary Care Nurse Practitioner | — | NULL | — |
| 363LP2300X | Primary Care Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 10/30/2020
- **Last updated:** 09/18/2023