Provider Demographics
NPI:1508804626
Name:GOYSICH, MARY CECILLE (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CECILLE
Last Name:GOYSICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5599
Mailing Address - Country:US
Mailing Address - Phone:662-377-4685
Mailing Address - Fax:662-377-2755
Practice Address - Street 1:4579 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6539
Practice Address - Country:US
Practice Address - Phone:662-377-3161
Practice Address - Fax:662-377-2993
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33538103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117696Medicaid
MSS76681Medicare UPIN