Provider Demographics
NPI:1265217939
Name:BADON, JUANTARIO (PCMHT)
Entity type:Individual
Prefix:
First Name:JUANTARIO
Middle Name:
Last Name:BADON
Suffix:
Gender:M
Credentials:PCMHT
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 18679
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8679
Mailing Address - Country:US
Mailing Address - Phone:601-705-1901
Mailing Address - Fax:601-705-1952
Practice Address - Street 1:301 ROBB ST
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:MS
Practice Address - Zip Code:39666-7053
Practice Address - Country:US
Practice Address - Phone:769-217-2810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6025101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor