Provider Demographics
NPI:1750878781
Name:PREMIER PROFESSIONAL COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:PREMIER PROFESSIONAL COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIN-LANE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, MPH
Authorized Official - Phone:228-220-4226
Mailing Address - Street 1:PO BOX 10743
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-0743
Mailing Address - Country:US
Mailing Address - Phone:228-220-4226
Mailing Address - Fax:
Practice Address - Street 1:1390 29TH AVE STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-1945
Practice Address - Country:US
Practice Address - Phone:228-220-4226
Practice Address - Fax:228-220-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC64621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05525369Medicaid