Provider Demographics
NPI:1811367113
Name:MISSISSIPPI BEHAVIORAL HEALTH TREATMENT INSTITUTE INCORPORATED INC
Entity Type:Organization
Organization Name:MISSISSIPPI BEHAVIORAL HEALTH TREATMENT INSTITUTE INCORPORATED INC
Other - Org Name:MISSISSIPPI BEHAVIORAL HEALTH TREATMENT INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KHARI
Authorized Official - Middle Name:ABAYOMI
Authorized Official - Last Name:OMOLARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-996-1758
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39603-7129
Mailing Address - Country:US
Mailing Address - Phone:601-996-1758
Mailing Address - Fax:601-797-8406
Practice Address - Street 1:394 IMPERIAL LN SW
Practice Address - Street 2:
Practice Address - City:BOGUE CHITTO
Practice Address - State:MS
Practice Address - Zip Code:39629-8231
Practice Address - Country:US
Practice Address - Phone:601-996-1758
Practice Address - Fax:601-797-8406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2522183Medicaid
LA3663198Medicaid
MS000126454Medicaid
MS009120058Medicaid