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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