Organization
REGION 8 MH/MR COMMISSION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVE VAN (EXECUTIVE DIRECTOR)
(601) 824-0342
Entity
Organization
Contact information
Practice address
613 MARQUETTE ROAD, BRANDON, MS 39042
(601) 824-0342
(601) 824-0349
Mailing address
PO BOX 88, 613 MARQUETTE ROAD, BRANDON, MS 39042
(601) 824-0342
(601) 824-0349
Taxonomy
Speciality
Code
Description
License number
State
103TM1800X
Intellectual & Developmental Disabilities Psychologist
Primary
R08-BMR-WAC-PREVOC-0
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
007700402
—
MS
Enumeration date
02/11/2010
Last updated
06/27/2022
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