Provider Demographics
NPI:1689847394
Name:REGION XII COMM ON MENTAL HEALTH DBA PINE BELT MENTAL HEALTHCARE
Entity Type:Organization
Organization Name:REGION XII COMM ON MENTAL HEALTH DBA PINE BELT MENTAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-544-4641
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 S 19TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-6171
Practice Address - Country:US
Practice Address - Phone:601-544-4641
Practice Address - Fax:601-584-4053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770355Medicaid