Provider Demographics
NPI:1154043495
Name:PRISM PSYCH, PLLC
Entity type:Organization
Organization Name:PRISM PSYCH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LATOYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAVRE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:423-748-2966
Mailing Address - Street 1:2817 BLACKFOOT RD
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-8321
Mailing Address - Country:US
Mailing Address - Phone:423-748-2966
Mailing Address - Fax:615-247-6510
Practice Address - Street 1:2817 BLACKFOOT RD
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-8321
Practice Address - Country:US
Practice Address - Phone:423-748-2966
Practice Address - Fax:615-247-6510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)