Provider Demographics
NPI:1912084286
Name:MIDSOUTH BEHAVIORAL HEALTH, PLLC
Entity Type:Organization
Organization Name:MIDSOUTH BEHAVIORAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCTS. MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-895-1707
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-0579
Mailing Address - Country:US
Mailing Address - Phone:662-895-1707
Mailing Address - Fax:662-893-0388
Practice Address - Street 1:6810 CRUMPLER BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1933
Practice Address - Country:US
Practice Address - Phone:662-895-1707
Practice Address - Fax:662-893-0388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty