Provider Demographics
NPI:1912214792
Name:DESOTO FAMILY COUNSELING CENTER PLLC
Entity Type:Organization
Organization Name:DESOTO FAMILY COUNSELING CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:662-772-5937
Mailing Address - Street 1:8626 AIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2603
Mailing Address - Country:US
Mailing Address - Phone:662-772-5937
Mailing Address - Fax:662-772-5940
Practice Address - Street 1:8626 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2603
Practice Address - Country:US
Practice Address - Phone:662-772-5937
Practice Address - Fax:662-772-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 2251P0200X, 225X00000X, 235Z00000X
MS2084P0800X
MS1326251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02332763Medicaid
MS03458834Medicaid
MS09250853Medicaid
MS04057773Medicaid
MS04073099Medicaid
MS09485302Medicaid
MS1558401521Medicaid
MS01128006Medicaid
MS03322249Medicaid
MS03350341Medicaid
MS05103380Medicaid
MS05476356Medicaid
MS09588552Medicaid
MS00432297Medicaid
MS01924277Medicaid
MS08579847Medicaid