Basic Information
| Provider Information | |||||||||
| NPI: | 1285222331 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGION ONE MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1046 | ||||||||
| Address2: | |||||||||
| City: | CLARKSDALE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386141046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626277267 | ||||||||
| FaxNumber: | 6626275240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1742 CHERYL ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSDALE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386147218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626277267 | ||||||||
| FaxNumber: | 6626275240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2021 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | GASTON | ||||||||
| AuthorizedOfficialFirstName: | DALYNDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING CLERK | ||||||||
| AuthorizedOfficialTelephone: | 6626277267 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 00018201 | 05 | MS | MEDICAID |