Provider Demographics
NPI:1437763240
Name:STARKVILLE WELLNESS GROUP
Entity Type:Organization
Organization Name:STARKVILLE WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:KETCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:662-425-1051
Mailing Address - Street 1:100 STARR AVE #K
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759
Mailing Address - Country:US
Mailing Address - Phone:972-898-2394
Mailing Address - Fax:
Practice Address - Street 1:100 STARR AVE #K
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:972-898-2394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-31
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04678598Medicaid