Provider Demographics
NPI:1568558161
Name:SOUTHERN MS PLANNING AND DEVELOPMENT DISTRICT
Entity Type:Organization
Organization Name:SOUTHERN MS PLANNING AND DEVELOPMENT DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAID WAIVER SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:228-314-1475
Mailing Address - Street 1:9229 HWY 49
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:228-868-2311
Mailing Address - Fax:228-863-2550
Practice Address - Street 1:9229 HWY 49
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-868-2311
Practice Address - Fax:228-868-2550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770319Medicaid