Basic Information
| Provider Information | |||||||||
| NPI: | 1023002920 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WARREN YAZOO MENTAL HEALTH SERVICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WARREN YAZOO MENTAL HEALTH SERVICE, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3444 WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391805331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016380031 | ||||||||
| FaxNumber: | 6016340234 | ||||||||
| Practice Location | |||||||||
| Address1: | 3444 WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391805331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016380031 | ||||||||
| FaxNumber: | 6016340234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VESSELL | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6016380031 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | R15-1 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 00018215 | 05 | MS | MEDICAID | 00770336 | 05 | MS | MEDICAID |