Provider Demographics
NPI:1124032677
Name:BATES, GERALDINE (LCSW)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:278 MARY MAGDALENE RD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8493
Mailing Address - Country:US
Mailing Address - Phone:601-307-5303
Mailing Address - Fax:
Practice Address - Street 1:248 E CAPITOL ST
Practice Address - Street 2:840 TRUST MARK BLDG
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-2503
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC0717101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800000316Medicare ID - Type UnspecifiedPROVIDER # WITH PARADIGM