Provider Demographics
NPI:1740007129
Name:EASTER SEALS MISSISSIPPI INC.
Entity type:Organization
Organization Name:EASTER SEALS MISSISSIPPI INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-432-2995
Mailing Address - Street 1:2901 S EASON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-5945
Mailing Address - Country:US
Mailing Address - Phone:682-432-2995
Mailing Address - Fax:817-303-9274
Practice Address - Street 1:2901 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-5945
Practice Address - Country:US
Practice Address - Phone:682-432-2995
Practice Address - Fax:817-303-9274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty