Basic Information
Provider Information | |||||||||
NPI: | 1922266311 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STOGNER | ||||||||
FirstName: | KRISTI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LSCW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 579 | ||||||||
Address2: |   | ||||||||
City: | SUMMIT | ||||||||
State: | MS | ||||||||
PostalCode: | 396660579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888990325 | ||||||||
FaxNumber: | 6012769327 | ||||||||
Practice Location | |||||||||
Address1: | 300 RAWLS DR STE 900 | ||||||||
Address2: |   | ||||||||
City: | MCCOMB | ||||||||
State: | MS | ||||||||
PostalCode: | 396482864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016848284 | ||||||||
FaxNumber: | 6016848199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2008 | ||||||||
LastUpdateDate: | 06/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C6391 | MS | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 08537384 | 05 | MS |   | MEDICAID |