Provider Demographics
NPI:1417349150
Name:FRESH START COMMUNITY SERVICES, LLC
Entity Type:Organization
Organization Name:FRESH START COMMUNITY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:C
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:601-954-2421
Mailing Address - Street 1:152 EDWARD OWENS DR
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-8921
Mailing Address - Country:US
Mailing Address - Phone:601-954-2421
Mailing Address - Fax:
Practice Address - Street 1:152 EDWARD OWENS DR
Practice Address - Street 2:
Practice Address - City:TERRY
Practice Address - State:MS
Practice Address - Zip Code:39170-8921
Practice Address - Country:US
Practice Address - Phone:601-954-2421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty