Organization
IGNITE CLINICAL WELLNESS GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DERRICK O ROACH (CHIEF OPERATIONS OFFICER)
(901) 859-2071
Entity
Organization
Contact information
Practice address
5600 GOODMAN RD STE G, OLIVE BRANCH, MS 38654-7002
(662) 985-4101
(662) 404-7288
Mailing address
5600 GOODMAN RD STE G, OLIVE BRANCH, MS 38654-7002
(662) 985-4101
(662) 404-7288
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
101YP2500X
Professional Counselor
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Enumeration date
07/27/2023
Last updated
07/27/2023
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