Provider Demographics
NPI:1659784569
Name:NORTH MISSISSIPPI COMMISSION ON MENTAL ILLNESS/MENTAL RETARDATION
Entity Type:Organization
Organization Name:NORTH MISSISSIPPI COMMISSION ON MENTAL ILLNESS/MENTAL RETARDATION
Other - Org Name:COMMUNICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:662-234-7521
Mailing Address - Street 1:152 HIGHWAY 7 S
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5392
Mailing Address - Country:US
Mailing Address - Phone:662-234-7521
Mailing Address - Fax:662-234-7558
Practice Address - Street 1:152 HIGHWAY 7 S
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5392
Practice Address - Country:US
Practice Address - Phone:662-234-7521
Practice Address - Fax:662-234-7558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSREG2-BIDD-HCS-01261QM0801X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018202Medicaid
MSC00099Medicare PIN