Provider Demographics
NPI:1982610572
Name:REGION 12 COMMISSION ON MENTAL HEALTH & RETARDATION PINE BELT MEN
Entity Type:Organization
Organization Name:REGION 12 COMMISSION ON MENTAL HEALTH & RETARDATION PINE BELT MEN
Other - Org Name:PINE BELT MENTAL HEALTH CARE RESOURCES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-705-1902
Mailing Address - Street 1:PO BOX 18679
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8679
Mailing Address - Country:US
Mailing Address - Phone:601-705-1906
Mailing Address - Fax:601-705-1952
Practice Address - Street 1:103 S 19TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-6171
Practice Address - Country:US
Practice Address - Phone:601-544-4641
Practice Address - Fax:601-584-4053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR12-1261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018212Medicaid
MSR121OtherDMH CERTIFICATION
MSR121OtherDMH CERTIFICATION