Provider Demographics
NPI:1023002920
Name:WARREN YAZOO MENTAL HEALTH SERVICE
Entity Type:Organization
Organization Name:WARREN YAZOO MENTAL HEALTH SERVICE
Other - Org Name:WARREN YAZOO MENTAL HEALTH SERVICE, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:VESSELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:601-638-0031
Mailing Address - Street 1:3444 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5331
Mailing Address - Country:US
Mailing Address - Phone:601-638-0031
Mailing Address - Fax:601-634-0234
Practice Address - Street 1:3444 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5331
Practice Address - Country:US
Practice Address - Phone:601-638-0031
Practice Address - Fax:601-634-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR15-1261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018215Medicaid
MS00770336Medicaid
MS00770336Medicaid