Provider Demographics
NPI:1558062604
Name:PRISM ONLINE THERAPY, LLC
Entity Type:Organization
Organization Name:PRISM ONLINE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LCSW
Authorized Official - Prefix:MR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW
Authorized Official - Phone:228-860-8824
Mailing Address - Street 1:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533-1087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 WELLINGTON LN
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3209
Practice Address - Country:US
Practice Address - Phone:601-283-8038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)