Provider Demographics
NPI:1801340799
Name:PROVIDENCE BEHAVIORAL HEALTH SERVICES
Entity type:Organization
Organization Name:PROVIDENCE BEHAVIORAL HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:KWONA
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:678-834-7615
Mailing Address - Street 1:5737 OLD NATIONAL HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3865
Mailing Address - Country:US
Mailing Address - Phone:678-834-7615
Mailing Address - Fax:
Practice Address - Street 1:5266 OLD HIGHWAY 11 STE 50
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-7818
Practice Address - Country:US
Practice Address - Phone:678-834-7615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health