Provider Demographics
NPI:1114469640
Name:DESOTO FAMILYCOUNSELING CENTER
Entity Type:Organization
Organization Name:DESOTO FAMILYCOUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-772-5937
Mailing Address - Street 1:6858 SWINNEA RD
Mailing Address - Street 2:BUILDING 4
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9493
Mailing Address - Country:US
Mailing Address - Phone:662-772-5937
Mailing Address - Fax:662-772-5940
Practice Address - Street 1:6858 SWINNEA RD
Practice Address - Street 2:BUILDING 4
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9493
Practice Address - Country:US
Practice Address - Phone:662-772-5937
Practice Address - Fax:662-772-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty