Provider Demographics
NPI:1972616076
Name:DATZ, GERALYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALYN
Middle Name:
Last Name:DATZ
Suffix:
Gender:F
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 1614
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1614
Mailing Address - Country:US
Mailing Address - Phone:601-255-1618
Mailing Address - Fax:601-255-1619
Practice Address - Street 1:1 COMMERCE DR
Practice Address - Street 2:STE 205
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1499
Practice Address - Country:US
Practice Address - Phone:601-255-1618
Practice Address - Fax:601-255-1619
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS45736103TC0700X
MS45-736103TH0004X
LA1140103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009933077Medicaid
MS06036275Medicaid
AL009933077Medicaid
MSQ02510Medicare UPIN