Basic Information
| Provider Information | |||||||||
| NPI: | 1376875252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORA | ||||||||
| FirstName: | JULIA | ||||||||
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| Credential: | M.H.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 884 CHURCH LN | ||||||||
| Address2: | APT 2A | ||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386718556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013151280 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3810 WINCHESTER RD | ||||||||
| Address2: | SOUTHEAST MENTAL HEALTH CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381186045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013691420 | ||||||||
| FaxNumber: | 9013691433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 02/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.