Provider Demographics
NPI:1952715757
Name:REGION IV ELDERLY OUTPATIENT PSYCHOSOCIAL
Entity Type:Organization
Organization Name:REGION IV ELDERLY OUTPATIENT PSYCHOSOCIAL
Other - Org Name:REGION IV MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPEARMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:662-286-9883
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-0839
Mailing Address - Country:US
Mailing Address - Phone:662-286-9883
Mailing Address - Fax:662-284-9836
Practice Address - Street 1:529 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-2258
Practice Address - Country:US
Practice Address - Phone:662-837-8122
Practice Address - Fax:662-837-9462
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGION IV MENTAL HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018204Medicaid