Basic Information
| Provider Information | |||||||||
| NPI: | 1518524883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | RICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 DORA STREET | ||||||||
| Address2: | |||||||||
| City: | WIGGINS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013106646 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 VETERANS AVE | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395312410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285235000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2019 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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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 | 104100000X | M9403 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | NONE | OTHER |