Basic Information
| Provider Information | |||||||||
| NPI: | 1184725533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NURSING HOME PSYCHOLOGICAL SERVICES OF MISSISSIPPI, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 661495 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352661495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059795882 | ||||||||
| FaxNumber: | 2059791248 | ||||||||
| Practice Location | |||||||||
| Address1: | 5250 GALAXIE DR | ||||||||
| Address2: | SUITE A-1 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392064311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568254135 | ||||||||
| FaxNumber: | 2568254135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILTON | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2568254135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 02551391 | 05 | MS | MEDICAID | 36-44944355 | 01 | MS | TRICARE | OTHER |