Provider Demographics
NPI:1811181019
Name:CASEY, CLARA DARLENE (MA)
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:DARLENE
Last Name:CASEY
Suffix:
Gender:F
Credentials:MA
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 18533
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8533
Mailing Address - Country:US
Mailing Address - Phone:601-325-7497
Mailing Address - Fax:
Practice Address - Street 1:2525 LINCOLN RD STE C
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3163
Practice Address - Country:US
Practice Address - Phone:601-255-8481
Practice Address - Fax:601-255-2862
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1445101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid