Provider Demographics
NPI:1437816162
Name:DELTA THERAPY GROUP, LLC
Entity Type:Organization
Organization Name:DELTA THERAPY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:VERLON
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:662-207-1869
Mailing Address - Street 1:612 SUNFLOWER AVENUE EXT STE 12
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-2333
Mailing Address - Country:US
Mailing Address - Phone:662-452-5072
Mailing Address - Fax:662-452-5072
Practice Address - Street 1:612 SUNFLOWER AVENUE EXT STE 12
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2333
Practice Address - Country:US
Practice Address - Phone:662-452-5072
Practice Address - Fax:662-452-5072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health