Basic Information
| Provider Information | |||||||||
| NPI: | 1922382258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIMPLE STROKES BEHAVIORAL AND MENTAL HEALTH GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 83 AIRWAYS PL | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623498787 | ||||||||
| FaxNumber: | 6623498757 | ||||||||
| Practice Location | |||||||||
| Address1: | 83 AIRWAYS PL | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623498787 | ||||||||
| FaxNumber: | 6623498757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMSON | ||||||||
| AuthorizedOfficialFirstName: | SHEILA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH DEPARTMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6623498787 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SIMPLE STROKES THERAPY CONSULTANTS, PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 35-594 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
No ID Information.