Provider Demographics
NPI:1891532305
Name:BEACON BEHAVIORAL OF MISSISSIPPI, LLC
Entity type:Organization
Organization Name:BEACON BEHAVIORAL OF MISSISSIPPI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAVESKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-962-3945
Mailing Address - Street 1:PO BOX 306603
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6603
Mailing Address - Country:US
Mailing Address - Phone:662-234-7601
Mailing Address - Fax:
Practice Address - Street 1:9035 E SANDIDGE RD STE 201
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3563
Practice Address - Country:US
Practice Address - Phone:662-408-4631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON BEHAVIORAL OF MISSISSIPPI, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty