Provider Demographics
NPI:1629578729
Name:KIDZPLAY COMMUNITY
Entity Type:Organization
Organization Name:KIDZPLAY COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BETHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-853-2184
Mailing Address - Street 1:1010 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2552
Mailing Address - Country:US
Mailing Address - Phone:910-853-2184
Mailing Address - Fax:
Practice Address - Street 1:1010 MONROE ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2552
Practice Address - Country:US
Practice Address - Phone:910-853-2184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty