Provider Demographics
NPI:1558765271
Name:LITTLE, MARY MARGARET
Entity Type:Individual
Prefix:MRS
First Name:MARY MARGARET
Middle Name:
Last Name:LITTLE
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
Mailing Address - Street 2:BLDG. B STE.4
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9266
Mailing Address - Country:US
Mailing Address - Phone:662-349-2733
Mailing Address - Fax:662-536-1849
Practice Address - Street 1:7160 TCHULAHOMA RD
Practice Address - Street 2:BLDG. B STE.4
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9266
Practice Address - Country:US
Practice Address - Phone:662-349-2733
Practice Address - Fax:662-536-1849
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS136079103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst