Provider Demographics
NPI:1720413479
Name:LOWE, PERSEPHONE ROSHALL (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:PERSEPHONE
Middle Name:ROSHALL
Last Name:LOWE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:PERSEPHONE
Other - Middle Name:ROSHALL
Other - Last Name:LOWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9851 HIGHWAY 178 STE A
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-3214
Mailing Address - Country:US
Mailing Address - Phone:662-299-4061
Mailing Address - Fax:662-874-6809
Practice Address - Street 1:9851 HIGHWAY 178 STE A
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3214
Practice Address - Country:US
Practice Address - Phone:662-299-4061
Practice Address - Fax:662-874-6809
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1717101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS822571852Medicaid