Provider Demographics
NPI:1003195967
Name:PSYCAMORE, LLC
Entity Type:Organization
Organization Name:PSYCAMORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:CMM
Authorized Official - Phone:601-939-5993
Mailing Address - Street 1:2620 EXECUTIVE PL
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-3717
Mailing Address - Country:US
Mailing Address - Phone:601-939-5993
Mailing Address - Fax:601-939-5935
Practice Address - Street 1:2620 EXECUTIVE PL
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-3717
Practice Address - Country:US
Practice Address - Phone:228-385-7744
Practice Address - Fax:601-939-5935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSDCS-PSYCAMORE-PHA-01261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health