Provider Demographics
NPI:1285222331
Name:REGION ONE MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:REGION ONE MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:DALYNDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-627-7267
Mailing Address - Street 1:PO BOX 1046
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-1046
Mailing Address - Country:US
Mailing Address - Phone:662-627-7267
Mailing Address - Fax:662-627-5240
Practice Address - Street 1:1742 CHERYL ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7218
Practice Address - Country:US
Practice Address - Phone:662-627-7267
Practice Address - Fax:662-627-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018201Medicaid