Provider Demographics
NPI:1689000317
Name:IRVING, AUGUST
Entity Type:Individual
Prefix:
First Name:AUGUST
Middle Name:
Last Name:IRVING
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:PO BOX 433
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-0433
Mailing Address - Country:US
Mailing Address - Phone:601-953-7064
Mailing Address - Fax:601-364-0264
Practice Address - Street 1:604 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4108
Practice Address - Country:US
Practice Address - Phone:601-953-7064
Practice Address - Fax:601-369-0264
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1789101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018209Medicaid