Provider Demographics
NPI:1538648027
Name:VALENTINE, TAJI J
Entity Type:Individual
Prefix:
First Name:TAJI
Middle Name:J
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7160 TCHULAHOMA RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9266
Mailing Address - Country:US
Mailing Address - Phone:662-536-3132
Mailing Address - Fax:
Practice Address - Street 1:7160 TCHULAHOMA RD BLDG B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9266
Practice Address - Country:US
Practice Address - Phone:662-536-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM6364101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health