Provider Demographics
NPI:1437773546
Name:CASTLEBERRY, DELISSA L (LPC, CADCII)
Entity Type:Individual
Prefix:
First Name:DELISSA
Middle Name:L
Last Name:CASTLEBERRY
Suffix:
Gender:F
Credentials:LPC, CADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7112 HOME OF GRACE DR
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-2728
Mailing Address - Country:US
Mailing Address - Phone:228-497-1312
Mailing Address - Fax:228-497-7340
Practice Address - Street 1:7112 HOME OF GRACE DR
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-2728
Practice Address - Country:US
Practice Address - Phone:228-497-1312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251B00000X, 101YA0400X
MS1412101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251B00000XAgenciesCase Management
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)