Provider Demographics
NPI:1093865933
Name:CHILDREN'S ACCELERATION PROGRAM, INC
Entity Type:Organization
Organization Name:CHILDREN'S ACCELERATION PROGRAM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:662-627-2741
Mailing Address - Street 1:PO BOX 1382
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-1382
Mailing Address - Country:US
Mailing Address - Phone:662-627-2741
Mailing Address - Fax:662-846-6306
Practice Address - Street 1:112 ISSAQUENA AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4315
Practice Address - Country:US
Practice Address - Phone:662-627-2741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR125740363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00020541Medicaid
MS00009266Medicaid