|
| |
|
2705 Clay St Vicksburg MS 39183-3130 | |
| (601) 661-9752 | |
| (601) 661-6021 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 2705 Clay St, Vicksburg, Mississippi |
| Authorized Official Name and Position | Joyce Blue (ADMINISTRATOR) |
| Authorized Official Contact | 6016619752 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 820472 Vicksburg MS 39182-0472 Ph: (601) 661-9752 | 2705 Clay St Vicksburg MS 39183-3130 Ph: (601) 661-9752 |
| NPI Number | 1306362082 |
|---|---|
| Provider Enumeration Date | 08/15/2017 |
| Last Update Date | 06/16/2018 |
| Medicare PECOS PAC ID | 8527325745 |
|---|---|
| Medicare Enrollment ID | O20171127000984 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1306362082 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Melissa F Smith |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1942256300 PECOS PAC ID: 0143257436 Enrollment ID: I20050719000309 |
| Provider Name | Ashley Anderson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1861835282 PECOS PAC ID: 8224279526 Enrollment ID: I20140923000111 |
| Provider Name | Christopher A Carson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1578986915 PECOS PAC ID: 8426376559 Enrollment ID: I20160708000108 |
| Provider Name | Beverly C Washington |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1952853731 PECOS PAC ID: 1759666829 Enrollment ID: I20170403000929 |
| Provider Name | Kimberly Shatwone Carson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1174052773 PECOS PAC ID: 7810288818 Enrollment ID: I20170727002711 |
| Provider Name | Lolita Denise Hartley |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306305487 PECOS PAC ID: 5496165169 Enrollment ID: I20220201000280 |
Vicksburg Center For Exceptional Children Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 107 Herrod St, Vicksburg, MS 39180 Phone: 601-218-5497 | |
Divine Home Care Changes Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 106 Ethel Dr, Vicksburg, MS 39180 Phone: 919-339-1854 | |
Nulife Healthcare, Llc Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 120 Holt Collier Dr Ste C, Vicksburg, MS 39183 Phone: 601-738-5565 Fax: 601-738-5544 | |
Cognitive Development Center Of Mississippi Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 1713 Clay St, Vicksburg, MS 39183 Phone: 601-883-1771 Fax: 601-883-1773 |