1912214792 NPI number — DESOTO FAMILY COUNSELING CENTER PLLC

Table of content: CARLA VIRAY LPT (NPI 1245554591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912214792 NPI number — DESOTO FAMILY COUNSELING CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESOTO FAMILY COUNSELING CENTER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912214792
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8626 AIRWAYS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-2603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-772-5937
Provider Business Mailing Address Fax Number:
662-772-5940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8626 AIRWAYS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-2603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-772-5937
Provider Business Practice Location Address Fax Number:
662-772-5940
Provider Enumeration Date:
09/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
662-772-5937

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251P0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 1326 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03458834 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03350341 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05476356 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01128006 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02332763 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09250853 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09485302 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04073099 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08579847 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01924277 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09588552 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1558401521 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00432297 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04057773 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05103380 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008579847 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03322249 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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