| Psychosocial Boutique, Pllc. | |
|
1330 Sunset Dr Grenada MS 38901-4000 | |
| (662) 892-2660 | |
| (662) 892-2660 |
| Full Name | Psychosocial Boutique, Pllc. |
|---|---|
| Speciality | Clinic/Center |
| Location | 1330 Sunset Dr, Grenada, Mississippi |
| Authorized Official Name and Position | Syrenia Leslie Winters (OWNER/PRACTITIONER) |
| Authorized Official Contact | 6628922660 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Psychosocial Boutique, Pllc. 1330 Sunset Dr Grenada MS 38901-4000 Ph: (662) 892-2660 | Psychosocial Boutique, Pllc. 1330 Sunset Dr Grenada MS 38901-4000 Ph: (662) 892-2660 |
| NPI Number | 1841846904 |
|---|---|
| Provider Enumeration Date | 08/14/2019 |
| Last Update Date | 02/22/2023 |
| Certification Date | 02/22/2023 |
| Medicare PECOS PAC ID | 7517298425 |
|---|---|
| Medicare Enrollment ID | O20191008000561 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1841846904 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Syrenia Johnson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1598113482 PECOS PAC ID: 2769713684 Enrollment ID: I20191008001049 |
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