Provider Demographics
NPI:1295827558
Name:SIMELTON, TIJUANA (BS, MHA)
Entity Type:Individual
Prefix:
First Name:TIJUANA
Middle Name:
Last Name:SIMELTON
Suffix:
Gender:F
Credentials:BS, MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BEECHWOOD CIR
Mailing Address - Street 2:HOUSE #56
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-6937
Mailing Address - Country:US
Mailing Address - Phone:662-750-4861
Mailing Address - Fax:
Practice Address - Street 1:2434 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6942
Practice Address - Country:US
Practice Address - Phone:662-640-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN734965000Medicaid