Provider Demographics
NPI:1285614370
Name:FLEMING, SAMUEL E III (PHD)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:E
Last Name:FLEMING
Suffix:III
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 1:211 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-3807
Mailing Address - Country:US
Mailing Address - Phone:662-844-9003
Mailing Address - Fax:662-844-9304
Practice Address - Street 1:211 N MADISON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-3807
Practice Address - Country:US
Practice Address - Phone:662-844-9003
Practice Address - Fax:662-844-9304
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL661103G00000X
MS46805103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01854707Medicaid
MS01854707Medicaid