Provider Demographics
NPI:1932742988
Name:PURE LIGHT PSYCHIATRY LLC
Entity Type:Organization
Organization Name:PURE LIGHT PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MACHELLE
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:662-420-1532
Mailing Address - Street 1:5600 GOODMAN RD STE B
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7002
Mailing Address - Country:US
Mailing Address - Phone:662-890-7010
Mailing Address - Fax:662-890-7044
Practice Address - Street 1:5600 GOODMAN RD STE B
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7002
Practice Address - Country:US
Practice Address - Phone:662-890-7010
Practice Address - Fax:662-890-7044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-22
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty