Provider Demographics
NPI:1366694820
Name:SOUTHWEST MISSISSIPPI MENTAL HEALTH MENTAL RETARDATION COMMISSION
Entity Type:Organization
Organization Name:SOUTHWEST MISSISSIPPI MENTAL HEALTH MENTAL RETARDATION COMMISSION
Other - Org Name:SW MS MENTAL HEALTH REGION XI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-684-2173
Mailing Address - Street 1:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0768
Mailing Address - Country:US
Mailing Address - Phone:601-684-2173
Mailing Address - Fax:601-249-4234
Practice Address - Street 1:1701 WHITE ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2711
Practice Address - Country:US
Practice Address - Phone:601-684-2173
Practice Address - Fax:601-249-4234
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST MISSISSIPPI MENTAL HEALTH MENTAL RETARDATION COMMISSION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018211Medicaid