Provider Demographics
NPI:1780852194
Name:MCWILLIE COUNSELING & DIAGNOSTIC SERVICES
Entity Type:Organization
Organization Name:MCWILLIE COUNSELING & DIAGNOSTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DELILAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:601-982-8624
Mailing Address - Street 1:5202 KEELE STREET, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206
Mailing Address - Country:US
Mailing Address - Phone:601-982-8624
Mailing Address - Fax:
Practice Address - Street 1:5202 KEELE ST STE 1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4355
Practice Address - Country:US
Practice Address - Phone:601-982-8624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00281261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)