Provider Demographics
NPI:1467637488
Name:SPECIALIZED TREATMENT FACILITY
Entity Type:Organization
Organization Name:SPECIALIZED TREATMENT FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:Y
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:228-328-6000
Mailing Address - Street 1:14426 JAMES BOND RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-8311
Mailing Address - Country:US
Mailing Address - Phone:228-328-6000
Mailing Address - Fax:228-328-6035
Practice Address - Street 1:14426 JAMES BOND RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-8311
Practice Address - Country:US
Practice Address - Phone:228-328-6000
Practice Address - Fax:228-328-6035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS981323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04333899Medicaid
MS1013922954OtherNPI