Provider Demographics
NPI:1730294968
Name:STOUDENMIRE, JOHN JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:STOUDENMIRE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 HOSPITAL ST STE 208A
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5311
Mailing Address - Country:US
Mailing Address - Phone:228-769-2311
Mailing Address - Fax:228-762-1240
Practice Address - Street 1:4211 HOSPITAL ST STE 208A
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5311
Practice Address - Country:US
Practice Address - Phone:228-769-2311
Practice Address - Fax:228-762-1240
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS61103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical