Provider Demographics
NPI:1598129090
Name:PLAY FABULOUS
Entity Type:Organization
Organization Name:PLAY FABULOUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:GUTHRIE-ALDINGER
Authorized Official - Suffix:
Authorized Official - Credentials:EDS, LPC-S,RPT, NCC
Authorized Official - Phone:901-412-2720
Mailing Address - Street 1:9761 DOROTHY DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6598
Mailing Address - Country:US
Mailing Address - Phone:901-412-2720
Mailing Address - Fax:
Practice Address - Street 1:9761 DOROTHY DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-6598
Practice Address - Country:US
Practice Address - Phone:901-412-2720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1239251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health