Provider Demographics
NPI:1891003331
Name:GERALYN DATZ PHD
Entity Type:Organization
Organization Name:GERALYN DATZ PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DATZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-434-9402
Mailing Address - Street 1:502 COURT ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3944
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 COURT ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3944
Practice Address - Country:US
Practice Address - Phone:601-434-9402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty