Provider Demographics
NPI:1891887808
Name:LOTT, WILLIAM C (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:LOTT
Suffix:
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-3110
Mailing Address - Fax:601-200-3109
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:ST THOMAS HALL
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-3110
Practice Address - Fax:601-200-3109
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS31466103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01505748Medicaid
MS01505748Medicaid