Provider Demographics
NPI:1891084414
Name:MISSISSIPPI CENTER FOR AUTISM AND RELATED DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:MISSISSIPPI CENTER FOR AUTISM AND RELATED DEVELOPMENTAL DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TISDALE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:228-806-9936
Mailing Address - Street 1:4061 SUZANNE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-3735
Mailing Address - Country:US
Mailing Address - Phone:228-396-4434
Mailing Address - Fax:
Practice Address - Street 1:4061 SUZANNE DR
Practice Address - Street 2:SUITE C
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-3735
Practice Address - Country:US
Practice Address - Phone:228-396-4434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty